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itgem.v.D': Polilzer, chromoiith. vD": C. Heitzmann. 



Lith-Anstv.F. Kbke, Wien . 



THE 

MEMBKANA TYMPANI 

HEALTH AND DISEASE. 

ILLUSTRATED BY TWENTY-FOUR CHROMO-LITHOGRAPHS. 



CLINICAL CONTRIBUTIONS TO THE DIAGNOSIS AND TREATMENT OF DISEASES OF 

THE EAR, WITH 



SUPPLEMENT. 



DR. ADAM POLITZER, 

OF THE UXHTERSITY OF TTEXNA. 



TRANSLATED BY 



A. IMATHEWSON, M.D., and H. G. NEWTON, M.D. 

ASST. S^JRGEO^'S OF THE BEOOKLT^^ EYE AND EAE HOSPITAL. 
MEMBERS OF THE AMER. OPHTHALMOL. AND OTOL. SOCIETIES. 




NEW YORK: 
WM. WOOD & CO., 61 WALKER STREET. 

1869. 







Entered according to Act of Congress, in the year 1869, by 

William wood & oo., 

In the Clerk's Oflace of the District Court of the United States for the Southern District of 

New York. 



The New York Printing Company, 

8i, 83, and 85 Centre Street, 

New York. 



1 



C0I5"TE]SrTS, 



PAGE 

Introduction 1 

Anatomy of the Membrana Tympani 7 

Microscopic Anatomy 10 

Inspection of the Membrana Tympani 15 

Color 21 

Lustre — Cone of Light 25 

Inclination 29 

Curvature 30 

Anomalies in Transparency and Color ... 33 

General Opacities 35 

Opacities of Epidermic Layer 36 

Opacities of Dermoid Layer 40 

Opacities of Substantia Propria. 50 

Opacities of Mucous Layer 54 

Circumscribed Opacities 56 

Calcareous Deposits , 58 

Tendinous Opacities 66' 

Peripheral Opacities 68 

Anomalies in Coherence 71 

Perforations — 

Causes 71 

Situation 74 

Size , 75 

Form 76' 

Appearances in ^ , 77 

Appearance of Ossicles and Promontory in 82' 

Kuptures 91 

Functional Disturbance in Perforations 92 



vi Contents. 

PAGE 

Healing of Perforations 93 

Eeproduction of Membrane 95 

[Note.] — Treatment of Chronic Catarrh of Middle Ear 101 

Formation of Cicatricial Membrane , 102 

Adhesion of Cicatrix to Promontory 110 

Perforation of Cicatrix 120 

Microscopic Character of Cicatrix 123 

Persistent Perforations 127 

[Note.]— Treatment of Purulent Catarrh of Middle Ear 128 

Detachment of Manubrium from the Membrane 130 

Fracture of Manubrium 133 

Adhesion of Membrane to Stapes 134 

Rare Conditions 136 

Anomalies in Curvature 139 

Abnormal Convexity of Membrane — 

G-eneral Protrusion 139 

Abscesses . . . , 140 

Granulations 142 

Hernial Protrusion 144 

Abnormal Concavity of Membrane — 

General Depression .* 146 

Circumscribed Depression 150 

Mobility of the Membrane — 

In Yalsalvian Experiment 152 

In the Act of Swallowing 154 

During Respiratory Movements 156 

Pulsatory Movements 156 

SUPPLEMENT. 

A. Accumulation of Serum in Tympanic Cavity — 

Diagnosis and Treatment 161 

Note 169 

B, A Method for Preventing the Closure of Artificial Perforations 170 

Note 179 

(7. Double Perforation of the Membrana Tympani 180 

D. Anatomy of the Membrana Tympani 181 



TEA]^SLATOES' PEEFACE. 



It is with pleasure tliat the translators present to the Ameri- 
can profession the following monograph npon the appearances 
of the membrana tympani in health and disease. We need not 
speak the praises of its author, for the name of Politzer is not 
only well known among aural surgeons, but is becoming famil- 
iar to the general practice, especially as connected with his 
method of inflating the middle ear. He has, however, placed 
us under still further obligation by this exhaustive treatise upon 
the membrane, which, to diseases of the ear, may stand in much 
the same relation as do works upon auscultation and percussion 
to diseases of the thorax. 

'No practitioner can undertake to diagnosticate the nature 
and extent of an aural afliection without a knowledge of the 
various appearances of the membrana tympani ; but with such 
knowledge the diagnosis is comparatively easy. Such a work 
as this of Politzer is therefore valuable. It throws light upon 
a field which is confessedly dark to many of our profession, and 
by means of it, in conjunction with a thorough general treatise 
(like the last edition of Troltsch), a practitioner may easily pre- 
pare himself to treat successfully in their early stages many of 



viii Preface, 

the cases which dow are allowed to go on to incurable deafness. 
The early stage of aural disease is the period when treatment is 
most likely to meet with success, and yet this is the very period 
in which it is too often neglected. 

We would call especial attention to the beautiful chromo- 
lithographs which accompany the work, and add greatly to its 
interest and value. 

We have delayed publication for some months in order to 
add the Supplement, which presents some of the results of more 
recent investigation. A portion of it, indeed, was written by 
Dr. Malhewson in Vienna, at the dictation of the Author, who 
also furnished original sketches to illustrate it. We would 
acknowledge the kindness of Dr. Politzer in permitting us to 
undertake the translation, and in rendering us assistance in the 
completion of our task. 

Arthue Mathewson, M.D. 

Homer G. I^ewton, M.D. 
Bbooklth, N, T,j August, 1869, 



MEMBEAIA TYIPAII. 



mXRODUCTIOxAT. 

The chief object in publishing this series of illustrations 
of the membrcma tympani is to assist the practitioner in 
the perception of those material changes which can be 
recognized in the membrane. 

A comparison of the appearances observed in the parts 
with the illustrations presented will furnish sm^e means 
for the recognition of any existing anomaly, and the ex- 
planation accompanying the figures will lead to a proper 
understanding of it. 

The value of these illustrations is at once apparent, if 
we consider the character of the diagnostic points gene- 
rally fm^nished by inspection of the membrane, as com- 
pared with the less reliable data obtained by other means. 

The extensive employment of inspection for the pur- 
pose of diagnosis is of very recent date. But we must 
already recognize its importance in the advancement of 
modern aural sm^gery, for it has considerably narrowed 
the former extraordinarily wide domain of nervous deaf- 
ness. Suj^ported by the investigations of pathological 
anatomy, which have authenticated important changes in 
the membrane in a considerable class of cases, inspection 



2 Memhrana Tympani. 

has materially advanced our knowledge of tlie morbid 
process. 

Such, a critical examination of changes perceptible in 
the membrana tympani was first made by Joseph Toyn- 
bee. After him, Wilde, supported by numerous observa- 
tions upon aural patients, directed attention to the more 
minute pathological changes, previously too little regarded. 
The most important results in this field, however, were 
furnished by the profound researches of von Troltsch. 
He compared his observations, made upon patients by 
means of an essentially improved method of examina- 
tion, with the corresponding post-mortem appearances ; and, 
from the harmony between conjectured and authenticated 
causes of disease, he showed with what brilliant success 
inspection of the membrana tympani may be employed 
for the diagnosis of pathological processes in the ear. 

Fully impressed with the importance of the subject, 
after the admirable researches mentioned, I applied my- 
self to its study with especial interest ; the more so, because 
the rich material of the clinics and of the several wards 
of the general hospital, as well as of the large asylums, 
was at my disposal. And since, in my opinion, the diag- 
nostic significance of any condition of the membrana tym- 
pani can only be correctly estimated and established by a 
comparison with the post-mortem condition, I recorded 
with especial care those cases in which there was near pros- 
pect of a post-mortem examination. The considerable 
number of such examinations has revealed to me a class 
of phenomena hitherto little regarded, which, as diagnos- 
tic points, are entitled to fuller notice. 



Introduction. 3 

An accurate examination of the membrana tympani is 
indispensable for a complete and exhaustive diagnosis. 
In consequence of its anatomical structure, the mem- 
brane stands in very intimate relation to the diseases of 
the external and middle ear. The lining of the external 
meatus, which is continuous over the external surface of the 
membrana tympani, and that of the tympanic cavity, cover- 
ing the inner surface, transmit to the membrane the morbid 
changes originating in themselves. The surfaces thus 
become the seat of appearances, which, revealed to us by 
inspection, permit a conclusion concerning the state of 
the external and middle ear. The lesions of the exter- 
nal and middle ear, on the whole, furnish the most fre- 
quent sources of functional disturbance in the auditory 
apparatus ; and, again, such disturbances are often asso- 
ciated with changes in the membrane. Therefore we find 
anomalies upon the membrana tympani in the majority 
of aural patients. 

Nevertheless, any one who has examined a large number 
of persons with normal hearing will become convinced, by 
repeated and accurate observation, that, in many cases, 
changes in the membrane can be proved to which no 
impairment of function whatever corresponds. These 
changes may be the results of a morbid process which 
has run its course at an earlier date with complete re- 
covery; and sometimes, also, they may be traced to con- 
genital malformations. On the other hand, experience 
teaches that, in some cases, with a pretty high degree of 
deafness, the membrana tympani does not present the 
least departure from the normal condition. 



4 Memhrana Tympani, 

Such a negative state cannot, of course, possess tliat 
diagnostic value whicli we attribute to the direct per- 
ception of characteristic signs ; still it permits the infer- 
ence, not to be undervalued, that the cause of the func- 
tional distui^bance is not in the vicinity of the membrana 
tympani, but in the deeper parts of the ear, — on the 
inner, labyrinthine wall of the tympanic cavity, or in the 
nervous apparatus. 

In the majority of cases, however, the changes met 
with in the membrane are indications of a morbid pro- 
cess present or past, and, in connection with the other 
signs, will contribute to the completion of the diagnosis ; 
for which indeed they are often alone sufficient. 

If, in spite of the perfection of the present method of 
illumination, dissection, in certain cases, does not verify 
the diagnosis, this depends upon the varying position of 
the membrana tympani hereafter to be described, which 
sometimes gives rise to illusions, whereby our estimate of 
the anomalies of curvature, and of the variations in color, 
lustre, and transparency, naturally becomes less reliable. 
But, as such difficulties are for the most part overcome 
by experience, they cannot materially diminish the prac- 
tical value of inspection. 

Considering all these results, we are satisfied that 
ocular inspection essentially facilitates the establishment 
of a diagnosis, not only in the cases where the condition 
of the membrane explains the existing functional disturb- 
ance, but in those also where an irregular, even inverse 
ratio exists between the two. Accordingly, we very 
often understand the nature of the lesion from the condi- 



Introduction, 5 

tion wlien illuminated, but are never able to infer from 
it the degree of functional disturbance. 

It is impossible to set up any fixed standard as tlie 
physiological condition of the membrana tympani. 
Color, lustre, transparency, and curvature, can, as a 
rule, be stated only approximatively. It is, therefore, 
only natui'al that the pathological conditions should also 
vary greatly, and that certain processes — perforations, 
calcareous deposits, and others — should occur in the most 
varied form and extent. We have, therefore, in the 
plates, selected the most exact types at our disposal, 
both of normal membranse tympani and also of the sev- 
eral kinds of pathological conditions. With a knovrledge 
of this fact, we believe that any condition met with by 
the practitioner may very easily be referred to the illus- 
tration, and, thus, any resulting deviation, though unes- 
sential, be at once discovered. The accompanying expla- 
nation of the figures is a faithful description of cases 
observed by us, and of results obtained by examination, 
and, consequently, best serves its purpose. 

Having, in these general remarks, as we think, stated 
the ground we take in the treatment of the subject 
before us, there remains only the pleasant duty of ex- 
pressing our heartfelt thanks; first, to Prof. Oppolzer, 
who, mth his usual liberality, has allowed us, for the 
purpose of investigation, the use of clinical material 
as well as that furnished by ambulant patients; next, 
to Professors Rokitansky, Skoda, Arlt, von Dumreicher, 
Hebra and Schuh ; to the visiting physicians, Chrastina, 
Dittl, Endlicher, Kolisko, von Peller, L. Politzer, Scholz, 



6 Membrana Tympani. 

Standhardtner, and Ulricli, for the readiness witli wHicli 
they placed at our disposal the rich material of their 
wards, and afforded us a fruitful field for observation. 



ANATOMT 



The anatomy of tlie membrana tympani, whicli is 
here presented before its pathology, has especial reference 
to the wants of practice. We therefore arrange together 
in a condensed statement its form, size, position, curvature, 
color, lustre, and transparency, as well as the microscopic 
texture ; because these constitute the basis of investiga- 
tion, and combine, when they have undergone change, to 
form the pathological condition. 

As regards relative ])osUion^ the membrana tympani is, 
as it were, a little membrane stretched obliquely do^vn- 
ward and inward at the end of a narrow tube, so that 
its plane forms mth the upper wall of the tube an 
obtuse, but with its lower wall an acute angle. It is 
inserted into an osseous groove, which is interrupted for 
a short space above ; and its form is thus determined 
by that of the surrounding ring. It is elliptical, irre- 
gularly oval, or, in case of more marked projection of 
the lateral portions of the ring, even heart-shaj^ed. 

We must here also notice a bulging out of the mem- 
brane at its anterior upper quadrant, over the tubercle of 
the malleus (short process), ])rojecting about a line above 
the interrupted portion of the groove. It begins at the 



8 Membrana Tympani. 

peripliery of tlie membrane, with an ill-defined base from 
a line and a half to two lines in breadth, has a rounded 
apex, and serves for the reception of the neck of the 
malleus. 

The size of the membrane, in like manner, depends upon 
that of the osseous ring, varying more or less markedly 
in different individuals. On account of this variety in 
form and size, it is extremely difficult to harmonize the av- 
erage measurements of difEerent observers. The greatest 
conformity is shown in the measurements of Hyrtl and 
von Troltsch. The former fixes the ratio of the leng-th 
to the breadth at four and three-tenths lines to four lines, 
while the latter states the greatest diameter, from above 
and anteriorly downward and backward, as from nine to 
ten millimetres ; the shortest diameter, from below and an- 
teriorly upward and backward, as from eight to nine. 

The inclination of the membrana tympani depends upon 
its relation to the walls of the external meatus, and in 
adults is the result of the inclination of the annulus tym- 
panicus to the axis of the meatus. The inclination of 
the tympanic groove, like that of an oblique section of the 
external meatus, naturally varies according to the differ- 
ences in its linear measurement from the anterior and 
lower to the posterior and upper wall of the meatus. The 
measurements instituted in this direction var^^, apparently, 
according as the several observers have different angles 
in view. Hyrtl states that the angle of inclination of 
the membrana tympani to the lower wall of the auditory 
canal is 50° ; while Huschke says that the two mem- 
branse tympani, if produced inward and downward, would 



Inclination — Curvature. 9 

cut eacli other at an angle of 130°. Von Troltsch, in 
measuring a large number of cases, reckons the average 
angle whicli the plane of the membrane forms with the 
upper wall of the auditory canal at 140°. 

In this position the membrana tympani is not stretched 
as a perfect plane upon the end of the external meatus, 
but is arched in such a manner that its concavity is 
presented outward, while its convexity is turned to- 
ward the inner wall of the tympanum. The deepest point 
of the arch, the so-called umho^ corresponds to the end 
of the handle of the malleus, inserted between the 
layers of the membrane. The whole membrane, in- 
deed, is thus curved, but upon closer examination the 
curvature is seen to be irregular, since the anterior and 
lower portion, passing from the umbo toward the peri- 
phery, exhibits a slight external convexity. There is also 
a marked conical pi'otrusion of the membrane at the point 
where the tubercle of the malleus presses it outward. 
It extends to either side in a longer posterior and a 
shorter anterior fold. 

The malleus is a structure intimately connected with 
the membrana tympani. Its short process or tubercle lies 
between the layers, soon to be described, in that part of 
the membrane pushed forward by it ; while its flat, haft- 
like process, the handle of the malleus, extends toward 
the centre of the membrane to end at the umbo in a spat- 
ula-shaped expansion. The neck of the malleus is at- 
tached at the bulging out mentioned above, whilst the 
head projects free into the cavity of the tympanum. 

The long malleus liandle imperfectly divides the mem- 



10 Memhrana Tympani. 

brane, as it were, into two parts, an anterior smaller and 
a posterior larger. 

The relation of tlie manubrium to the membrana tym- 
pani, leads directly to the examination of the onicroscopic 
anatomy of the membrane, for an accurate knowledge 
of which we are chiefly indebted to the thorough researches 
of Von Troltsch, Toynbee, and Gerlach. 

According to these, the membrane, as already known 
to older observers (Linke), consists essentially of three 
layers ; a middle fibrous — the so-called lamina propria 
m^emhranw tympany an external dermoid and an inter- 
nal mucous layer — the two coats which the proper fibrous 
layer receives from the lining of the external meatus, and 
from that of the cavity of the tympanum. The dermoid 
layer is an extremely delicate continuation of the lining 
of the external meatus, which, also, in its transition 
to the membrane, consists of an epidermic layer, a Mal- 
pighian mucous layer, and the cutis, but contain no glan- 
dular elements or papillae, and only a very little con- 
nective tissue. The latter, in its arrangement, differs 
essentially from the connective tissue of the lamina pro- 
pria^ and appears to serve as a firm covering to the 
vessels and nerves distributed to the external coat. 

The middle fibrous layer consists of two separable 
laminae — an external radiate, and an internal circular. 
The pale, riband-like, sharply but delicately defined 
fibres of both these lamellae, form a tissue, which, accord- 
ing to Gerlach, holds, as it were, an intermediate place 
between the ordinary fibrillated, and the homogeneous 
connective tissue of Eeichert. The external radiating 



Microscopic Anatomy. 11 

fibres take tlieir origin from tlie tendinous ring {annulus 
cartilagineiis)^ and in the lower segment are inserted 
into tlie spatula-shaped end of the flattened malleus han- 
dle, but in the upper portion are attached to its anterior 
edge. They thus increase the thickness toward the cen- 
tre, though but slightly ; partly, because they are multi- 
plied by division of fibres, and, partly, through accumula- 
tion at the umbo (v. Troltsch). Above, toward the neck 
of the malleus, the layer always becomes more delicate, 
so that upon the short process it is no longer possible to 
recognize distinct radiating fibres. The inner circidar 
fibrous layer is formed of concentrically arranged fibres, 
which are wanting at the extreme periphery, but are 
very abundant near to it. They gradually become 
more scanty toward the centre, where the membrane 
appears almost homogeneous, with only scattered traces 
of circular fibres. Imbedded between the fibres of 
both these layers are the so-called corpuscles of the 
membrana tympani, named, after their discoverer, " the 
corpuscles of Troltsch." They appear fusiform in a lon- 
gitudinal section, stellate in transverse, and are analogous 
to the corpuscles of the cornea. They vary in form and 
relative position in both layers, and by their long, deli- 
cate processes both anastomose with each other, and also, 
in part, extend to the contiguous layer. 

The handle of the malleus is inserted between the 
radiate and circular fibrous layers, and, according to v. 
Troltsch, through a slit in the circular fibres, so that the 
uppermost portion of them lies external to the neck of 
the malleus, while the lower and larger pai-t is behind, 



12 Membrana Tympani. 

thus surrounding the neck, as it were, with a ruffle. 
According to Gerlach, however, no circular fibres pass 
external to the handle. 

The inner or mucous layer of the membrana tympani, 
a continuation of the mucous membrane of the cavity of 
the tympanum, through marked thinning of the connec- 
tive tissue, consists almost entirely of a single layer of 
pavement epithelium. Upon this mucous layer Gerlach 
has found prominences in considerable numbers, some- 
times globular, like the papillae of the tongue, and some- 
times finger-shaped, analogous to the villosities of the in- 
testines. The former attain such a marked size that 
with transmitted light they can be seen by the naked 
eye. They consist throughout their central portions of 
ordinary connective tissue, but at the periphery are 
more homogeneous in structure. They contain one or 
more loops of capillaries, but no recognizable nerves, and 
are covered with a multifold layer of flattened epithe- 
lium. Since they are each connected with the mucous 
membrane only by a pedicle, Gerlach describes them as 
its villi. 

Von Troltsch further describes a duplicature of the 
membrana tympani, extending from its posterior upper 
border forward to the manubrium, and forming a pocket 
with the external part of the membrane. It consists of 
fibrous elements connected with the circular fibres, is 
covered with thinned mucous membrane, and frequently 
contains mucus. Von Troltsch names the space en- 
closed by it " the posterior pocket of the membrana tym- 
pani," to distinguish it from "the anterior pocket," which 



.9 — Nerves. ^ 13 

latter is bounded by an osseous projection arcMng over 
tlie neck of the malleus, by the processiis gracilis^ the 
ligamentum mallei anterius^ the cliorda tynvpan% the 
arteria tyirvpani inferior^ and the mucous membrane. 

The membrana tympani has hvo plexuses of vessels 
completely separated by the non-vascular substantia 
propria^ except at the periphery, where they anasto- 
mose with each other. Of these, the external belongs to 
the connectiye tissue lying between the epidermis and the 
radiate fibres, whilst the inner belongs to the mucous 
membrane (mucous layer). The external plexus is de- 
rived from the arteria auricularis profunda^ which sends 
a branch to the centre of the membrane. This, by nu- 
merous radiating twigs, forms a wreath of capillary ves- 
sels upon the periphery, whose recurrent veins unite at 
the centre into two larger trunks, to run outward on 
either side of the artery, parallel to the manubrium. 
The plexus of the mucous membrane arises from the ves- 
sels of the tympanic cavity. It is a pure capillary system, 
with tolerably close meshes, and is developed from an ar- 
tery of the ca\T.ty of the tympanum, which runs parallel 
to the manubrium upon the inner side of the membrane. 

The nerves of the membrana tympani — ^which Arnold 
thought had their origin in the nervus temporalis super - 
ficialis^ from the trigeminus^ but which were first care- 
fully examined by Troltsch — run in the outer layer par- 
allel to the vessels, in three or four very delicate, dimly 
outlined branches, whose terminations are as yet un- 
known. Gerlach, moreover, once observed fine mar- 
rowless fibres in the mucous coat also. 



14 Membrana Tyrwpaiii. 

Tlie anatomical relations liere detailed correspond to 
the middle period of life. Many noteworthy deviations 
are presented in early cliildliood, in consequence of in- 
complete development of the bones of the skull. 

The j;)osition of the membrane in the new-born and in 
children is referable chiefly to the inclination resulting 
from a greater approximation of the whole temporal 
bone to the base of the skall. At this period the osse- 
ous meatus is wanting, the inclination of the annulus 
tymjpanicus^ and consequently that of the plane of the 
membrane, approaches the plane of the base of the cra- 
nium. With further development, the lateral portions 
of the skull push outward and upward, and, upon the 
addition of the osseous canal, the annulus tympanicus 
acquires the position described above. 

With respect to size^ the differences of age exert but 
little influence, because the ring, and consequently, also, 
the membrane, have almost reached their full develop- 
ment at a very early period. 

Yon Troltsch : Zeitschrift fur wissenschaftliche Zoologie. Bd. IX. 

und aiigewandte Anatomie des Ohres. 1861. 
Toynbee : Diseases of the Ear. 1862. 
Gerlach : Mikroskopische Studien aus der menschlichen Morphologie. 



INSPECTION. 



An accm'ate knowledge of the normal and pathological 
relations of tlie membrana tympani in the living depends 
chiefly upon rational methods of examination. If, in later 
times, we can show any real progress in the critical exam- 
ination of the conditions of the membrane, and in the es- 
timation of their diagnostic value, it is to be attributed, 
not alone to pathologico-anatomical investigations, but 
also to marked improvements in the methods of exami- 
nation. 

Formerly we could not, in general, obtain a sufficient- 
ly clear idea of the conditions of the membrane, because, 
undertaken with, such imperfect means, the examination 
was necessarily unsatisfactory. The vahnilar ear specula 
of Kramer, which then came into use and are still employed 
by many observers, were intended to give a view of the 
membrana tympani without the aid of a reflector, simply 
by dilatation of the external meatus. They do not, how- 
ever, fully meet the requirements of the practitioner. The 
inadequacy of this instrument is chiefly due to the im- 
possibility of dilating the cartilaginous canal by its pres- 
sure. But this distention of the resistant canal is of minor 
importance for obtaining a distinct view. The main point 
is to illuminate sufficiently a membrane stretched at the 



16 Membrana Tympam. 

end 'of a dark tube. But if this illumination by the 
direct entrance of the sun's rays, or of artificial light, 
were fully sufficient in itself, still, the observer, in order 
to avoid obstructing the light with his head, must be at 
too great a distance to perceive clearly the more deli- 
cate shades of the membrane, and have a sufficiently 
large portion of it in view at once. 

These inconveniences could of course be overcome by 
combination with a reflector, if the hairs, growing in the 
cartilaginous canal, by insinuating themselves between 
the opened branches of the instrument, did not interfere 
too much with the field of vision. The disagreeable, at 
times painful sensation experienced by the patient in the 
attempted dilatation is also to be considered a disadvan- 
tage in this valvular speculum. 

Far more advantageous for the purpose of examination 
are the more recently constructed uncleft specula, which, 
first employed by Dr. Ignaz Gruber, have received many 
modifications in size and f orm fi'om Arlt, Toynbee, and 
Wilde. They are made of metal, are funnel-shaped or 
like a truncated cone, and have a polished or blackened 
inner surface, and a round or oval aperture, the latter 
difference, however, having little influence in the examina 
tion. There are three sizes, designed for corresponding 
differences in the calibre of the meatus. 

Quite lately, an essential improvement has been intro- 
duced at our suggestion by Leiter of Vienna, who em- 
ploys hard rubber for this purpose. These rubber 
specula have the advantage of being much lighter, and 
are therefore borne in the meatus by the patient, mthout 



MetJiod of Examination, 17 

support far more easily tliaii tlie liea^y metallic cones, 
and, moreover, do not occasion tlie unpleasant cold sen- 
sation caused by a polislied metal surface. The dark 
ground of tlie inner surface favors a clear definition of 
the illuminated parts far more than does the slight reflec- 
tion of light fi'om the polished metal, which increases the 
brightness of the view at the centre. Moreover, the blunt 
edges of the rubber entirely prevent the wounding of 
the lining of the meatus, a thing which is always possible 
in the use of the metal specula. 

These specula, together with a centrally perforated 
concave reflector, of fi^om four to five inches diameter and 
having a focal distance of from four to six inches, furnish, 
with moderate light, a perfectly defined illuminated view, 
while the distance from the observer's eye to the object is 
comparatively short. 

This method of examination, which owes its mde intro- 
duction especially to Yon Troltsch, is much more acces- 
sible, convenient, and safe for the practitioner than that 
by means of the valvular sj)eculum already mentioned. 
We do not for a moment doubt that the inventor, — who 
has been of great service to aural surgery, — ^has, by his 
long experience and skilful practice, obtained the same 
clear and perfect results in the use of his speculum as 
those given by the newer method. Still, that instrument, 
which fi'om the outset makes too great demands upon 
the general practitioner, is to be estimated far below 
the later, more reliable means of examination. 

This new method, by the use of a concave mirror, 

secures the illumination of the membrana tympani, 

2 



18 Memhrana Tym^ani. 

either witli ordinary daylight or artificial light. The 
latter is employed at the bedside^ especially in badly 
lighted rooms and very cloudy weather. An ordinary 
moderator lamp, mthout the diffusing porcelain shade, 
answers the purpose very well ; or better still, a white 
light — for instance, that from camphene. Although 
the condition will be made sufficiently clear to experts by 
this illumination, still the artificial light has the disad- 
vantage of altering more or less the shades of color in 
the membrane, thereby disturbino; in some de2:ree its 
general appearance. 

For this reason ordinary daylight, as it gives the most 
natural, appearance to the membrane, is far preferable to 
all other kinds of light. Only a diffuse light is of value, 
falling upon the mirror as clear as possible fi'om a fair 
sky, from isolated white clouds, or by reflection from a 
bright wall. The direct rays of the sun, by dazzling 
the eye of the observer, impair the distinctness of the 
object. 

11\^ position of the patient during the examination is 
of considerable importance for obtaining a distinct 
view. The ear should neither be turned directly to- 
ward, nor away from, the source of light; but must 
rather be fixed in a somewhat lateral position, turned 
more from the light than toward it, so that the rays, 
falling upon the mirror and reflected from it, com- 
pletely illuminate the external meatus without the head 
of the patient intercepting any portion of them. 

In order to introduce the speculum into the meatus 
thus illuminated, it is necessary, with the index and mid- 



Ill limitation, 19 

cUe fiiio-ers of tlie left liand, to draw the concha backwaixl 
and upward, as well as somewhat toward the observer. 
By this means the axes of the osseous and cartilaginous 
canals, which in the natural position form an angle with 
each other, fall into a more direct line and permit a free 
inspection of the membrane. 

After these preliminaries, the rubber or the metallic 
speculum, slightly warmed by the breath, is pushed 
forward with a slow rotary movement into the 
cartilaginous meatus, until the hairs interfering mth 
vision are completely pressed aside by the walls of the 
instrument. The mirror being held in the surgeon's 
right hand, the reflection is now thrown through the 
speculum into the meatus, and the mirror is carried to 
such a distance fi'om the ear that the greatest intensity 
of light falls upon the membrana tympani (focal dis- 
tance). Nevertheless, in very few cases can we see the 
whole membrane at a glance ; and therefore, to inspect 
the various parts of it successively, movements in all 
directions, both of the speculum by means of the free 
thumb of the left hand, and of the reflector, are neces- 
sary ; the observer's eye likewise following them through 
the central aperture. 

In this manner, as a rule, we obtain the clearest views 
of the membrane. If, however, in certain cases, in spite 
of strict adherence to the method mentioned, the prac- 
titioner is able to obtain only an imperfect view, or none 
at all, it is due to ^various ohstmictions^ sometimes 
occurring in the osseous, sometimes in the cartilaginous 
canal, and sometimes in both. These may have the 



20 Memhrana Tympani. 

character of normal, or of pathological formations. In 
the first place, there is an abundant groivtJi of hair in the 
cartilaginous meatus, extending even into the osseous 
canal, which interferes with the examination whenever the 
more deeply seated hairs cannot easily be reached and 
pushed aside by the speculum. If it should be impossible 
to remove this impediment by means of the scissors, it 
may be overcome very easily by smearing the projecting 
hairs with a little wax and fixing them to the external 
meatus. Abundant accumulations of cerumen are also a 
hindrance, sometimes as stoppers filling up the oj)ening 
of the meatus, sometimes spread out upon its walls so 
thick as to greatly diminish the calibre of the canal. 
The removal of the abnormal accumulation may be 
accomplished by soaking or syringing, or, in some cases, 
simply by the use of the ear-scoop. Detached e^yiderrmc 
scales^ and whitish epidermal lamince of pearly lustre, 
hanging in membraniform or stringy shreds, for the 
most part in the osseous portion of the meatus, should be 
very carefully removed by means of the bent forceps. 

More important, because beyond the possibility of re- 
moval, are the obstacles to examination which arise 
from congenital narroiving of the meatus or too great 
curvature of its anterior wall. This constriction is ac- 
companied by an insufiicient illumination of the field, 
whilst the more or less pronounced curvature inter- 
feres with the inspection of the entire membrane to such a 
degree, that the portions lying before the malleus handle 
are entirely withdrawn from observation, and sometimes 
the handle itself can hardly be recognized. 



Ohstructions — Color of Membrane, 21 

Amono^ the morbid cliaiio'es wliicli render tlie niembrana 
tympani temporarily or j^ermanently inaccessible to ex- 
amination, especially prominent are tlie inflammatory 
affections of tlie lining of the meatus, accompanied by 
constriction, the accumulation of pus and mucus, granu- 
lations, polypi and exostoses. 

When the membrane is brought clearly and fully to 
view by a pro2:)er illumination, then its color, transpa- 
rency, lustre, inclination and curvature, as well as the 
position of the handle and short process of the malleus, 
are to be individually noticed ; since their relations to 
each other, as a whole, determine the characteristic ap- 
pearance of the normal, as well as of the pathological 
membrane. 

Concerning the color of the normal membrana tym- 
pani we find very different statements in the text-books 
of anatomy and aural surgery. Whilst some authors 
characterize it as clear and transparent, it is described 
by others as pearl-gray or quite white. This difference 
of opinion is explained, if we remember that the anat- 
omist finds in the cadaver a different condition of the 
membrane from that which the |)ractitioner meets during 
life. A further source of disagreement arises partly in 
the different methods of investigation employed by the 
various authors, and in a disregard of those elements that 
go to make up the color of the membrane ; and partly in 
the fact that they have not taken into account differences 
of age, which, howevei*, in a great number of cases, exer- 
cise an influence upon the color. First of all, it must be 
borne in mind that the membrana tympani is a dull. 



22 Merribrana Tympaiii. 

translucent medium, wliicli reflects a portion of the llglit 
tlirown upon it, but permits a portion to pass through, 
illuminating the tympanic cavity. A paii; of this 
light reaches the eye by being reflected back through 
the membrane, especially from the promontory oppo- 
site. The color of the membrana tympani is there- 
fore a combination of colors, dependent upon those pe- 
culiar to the membrane and the kind of light employed, 
and upon the number and shade of the rays reflected 
from the promontory. Y\iq jpecidiar shade of the mem- 
brane cannot be accm^ately determined dming life, since 
the kind of light and the surroundings exercise so 
great an influence upon it; and in the dead subject, 
where the natural color suffers through maceration 
of the epidermic layer, or through evaporation, it is im- 
possible to draw an approximatively correct conclusion 
concerning it. In all cases, the hind of light employed 
in the examination has considerable influence upon the 
color of the membrane. Of this fact one is easily con- 
vinced, if, in the manner above mentioned, he examines 
the same membrane with light fi^om a clear blue sky, 
and then mth that from an oil lamp. In the former case, 
a delicate blue tint will be recognized upon the mem- 
brane (PI. 1, Fig. 1), whilst in the latter it mil acquire an 
orange hue (PL 1, Fig. 3). The quantity and color of the 
light reflected from the promontory depend, first, upon 
the degree of transparency of the membrane ; next, upon 
its distance from the promontory ; and finally, upon its 
inclination to the axis of the auditory canal. The more 
oblique the position of the membrane, the thicker is the 



Color of the Normal Memhrane. 23 

stratum of its substance through whicli the rays of light 
reflected from the promontory must pass in order to 
reach the eye ; and hence, also, the intensity of the light 
is diminished. 

For these reasons, therefore, a description of the nor- 
mal condition of the membrana tympani will be difficult ; 
aside from the fact that opacities, to be described here- 
after, exist in a considerable number of persons having 
normal hearing. We cannot properly speak of the color 
of the membrane as a whole, since the different parts of 
it, with the same light, are differently tinted. In cases 
wliere we characterize the membrane as normal in ap- 
pearance, its color, viewed by ordinary daylight, most 
nearly approaches a neutral gray, mingled with a weaker 
tint of violet and light yellowish-bro^AOi. The gray of 
the anterior portion, which lies in the angle between the 
manubrium and the cone of light, is very dark ; whilst 
that of the posterior is clearer. The shade of this poste- 
rior portion of the membrane is often modified at its 
upper boundary by the pocket of Troltsch, situated on the 
inner surface, which with the cliorda tympani running 
along its lower border gives to tolerably transparent 
membranes a whitish-gray opacity, concave below, and 
extending backward from the manubrium. When the 
membrane is transparent, the lower part of the illumi- 
nated long shank of the incus is often seen behind the 
manubrium, though not extending as far down. Indeed, 
in some cases, where the membranes were almost trans- 
parent, I have distinctly seen, not only the long shank of 
the incus, but even the posterior shank of the stapes (PL 1, 



24 Membrana Tympcmi, 

Fig. 4). Tlie membrane has also a somewhat yellow- 
ish-gray color near its centre, at the lower end of the 
manubrium and a little behind it, on account of the pale 
yellow rays reflected fi-om the promontory (PL 1, Figs. 
1, 2, 3, 4, at the centre). A glimmering lustre is not un- 
frequently mingled with this color behind and near the 
handle of the malleus, proceeding fi^om a faintly lustrous 
spot upon the moist and smooth mucous membrane of 
the promontory. 

Besides these general diversities in the normal appear- 
ance of the membrana tympani, others are also found 
which de|)end U23on age. In childhood the membrane 
often has a somewhat grayish opacity and dullness, 
though not unfrequently it is transparent and lustrous, 
as in adults. In children, however, the much darker 
gray of the membranes and the infrequency of the trans- 
mission of light through them fi'om the promontory are 
often remarkable. In old age, also, we frequently find 
changes, such as a uniformly gray, often lustreless ap- 
pearance. 

The opacity caused by the sliort process of the malleus^ 
and the yelloiv^ sjxttula-sliaped end of tlie lictndle^ is fur- 
thermore to be considered as normal. The short process is 
visible (PL 1, Figs. 1, 2, 3, 4) uj)on the anterior upj)er 
border of the membrane as a white, pointed tubercle, 
passing abruptly into the manubrium, which, lying in the 
membrane, extends as a yellowish-white strij)e backward, 
downward, and toward its centre. Upon the manubrium 
the radiate fibres of the substantia propria for the most 
part accumulate, and, from being crowded together in a 



Normal Opacities — Kormal Lustre. *25 

limited space, occasion the opacity mentioned. Another 
opacity, sometimes occurring in the normal condition, is 
peripheral, and appears in the form of a tendinous gray 
zone, not unlike the arcus senilis^ and is located at the 
annidus cartilagineus (peripheral thickening of the cir- 
cular fibres), especially upon the anterior border of the 
membrane. 

The lustre of the membrane is of importance in diag- 
nosticating its condition, inasmuch as, in many cases, 
from the absence or the change in form and size of the 
so-called cone of liglit during movements of the mem- 
brane, we are able to judge, not only of the condition 
of the membrane itself, but also of that of the Eustachian 
tube. In addition to a soft lustre spread over the whole 
'membrane (Troltsch), there is this sharply marked cone 
of light upon its anterior portion in the anterior 
lower quadrant. It is triangular, and, with its aj)ex 
at the end of the malleus handle, it spreads out 
downward and forward in such a manner that it 
makes with the manubrium an obtuse angle anteriorly 
(PL 1, Fig. 1). This angle will vary inversely as the in- 
clination of the membrana tympani to the auditory canal. 
There are varieties in the extent and form of the lio-ht 
spot in different individuals. These arise, as we shall 
see hereafter, partly from differences of inclination, and 
partly from those of curvature. In its regular form, the 
cone of light is ordinarily from one and a half to two milli- 
metres in breadth at it^^base. In many cases it is interrupt- 
ed in its continuity, so that between the apex and base 
there is a portion without reflection (PL 1, Fig. 3). 



26 Memhrana Tympani. 

Sometimes it is divided longitudinally into two parts, or 
finely striped. In certain cases it extends to tlie circum- 
ference of the membrana tympani ; in others, the peri- 
pheral portion fades out (PL 1, Fig. 2), and only the 
apex remains as a little, irregular light spot. The know- 
ledge of all these varieties of normal condition is of 
importance, because, if disregarded, they might, in cases 
of disease, easily lead to erroneous conclusions. 

Different views prevail among authors respecting the 
cause of this light spot. Wilde seeks an explanation in 
an external convexity of the membrane at this point. 
Although the curvature here undoubtedly has an influence 
upon the size and form of the light spot, yet it is of 
minor importance in its production. The chief cause 
is the inclination of the membrane to the axis of the 
auditory canal, together with the concavity of the mem- 
brane produced by the manubrium. 

If we carefully dry a preparation of the normal ear, and 
then throw light upon the membrana tympani through 
the meatus, we shall see the triangular light spot in the 
same place as in the living. Just as in the living, too, it 
is displaced very little by moving the eye in different 
directions; because the axis of vision, corresponding so 
nearly to the axis of the meatus, can change little with 
respect to its inclination to the membrane. If we re- 
move the canal from the membrana tympani so that the 
membrane remains exposed in its osseous groove, and 
turn it so that its other portions successively acquire the 
position of the original cone of light, now at all these 
points we perceive a reflection of light which in the 



Cone of Light 27 

neigliborliood of tlie former cone of liglit lias nearly 
the same form. Upon tliose portions beliincl tlie handle, 
however, it generally appears large, irregular, and faint, 
on account of the great difference between their curva- 
ture and that of the anterior portions. 

Is it now asked upon what does the cone of light de- 
pend ? No light would be reflected to the eye from 
the membrane if it were a plane surface; for, with 
its inclination to the auditory meatus, all rays thrown 
upon it would, according to the laws of optics, be 
reflected against the anterior lower wall of the canal. 
In consequence, however, of the inward curvature of the 
membrane from the traction of the malleus handle, its 
parts undergo such a change of inclination that the 
anterior portion stands directly at right angles to 
our axis of vision, and the light thrown upon it is re- 
flected back to the eye. You can convince yourself of 
the correctness of this oj)inion by stretching a shining 
animal membrane over a large ring, and giving it the 
inclination of the membrana tympani. You Avill per- 
ceive no reflection if you examine it, holding the mirror 
relatively in the same direction as that in which you 
view the membrana tympani. But such a reflection will 
at once be seen at the spot where the cone of light is 
found on the membrana tympani, if the central portion 
be arched by pressure or traction inward. 

Consequently, we cannot agree with Wilde respecting 
the cause of the cone of light ; and Von Troltsch justly 
remarks that it is found not only upon the surface of the 
externally convex portion of the membrane mentioned 



28 Menibrana Tym2yani. 

by Wilde, but also ujDon concave portions, its apex 
indeed being visible at tlie umbo — the most concave part 
of the membrane. 

Althouo^h it is evident from the foreo^oinsr statements, 
that no conclusion respecting changes in the membrana 
tympani, or in the cavity of the tympanum, can be 
drawn fi'om the form, size, or absence of this reflection 
of light, — since changes in the cone of light, like those 
often met with in disease, are sometimes found in persons 
of normal hearing, — still, in many cases, we can make 
use of the light spot in determining the pervious- 
ness of the Eustachian tube. If, for instance, air is 
forced into the cavity of the tymjDanum by the Yalsal- 
vian experiment ; or, during the act of swallowing, it is 
drawn out, on examining the light spot we shall see a 
change in its form, since the curvature of the membrane 
must necessarily be altered by these sudden variations in 
the pressure of the air in the tympanic cavity. If, then, 
during the aforesaid manipulations, we perceive an altera- 
tion in the cone of light, we can say with certainty that the 
tube is open, though we can by no means infer the con- 
trary from the absence of change in form and size. Fre- 
quently, during very quick and strong changes in the 
pressure of the air — for example, in catheterization — even 
in the normal condition, not the slightest movement of the 
membrane is visible ; though a small aural manometer in- 
troduced into the meatus proves, beyond a doubt, by the 
movement of a little drop of fluid in it, the existence of 
a change of curvature. 

Besides this light spot, which in disease undergoes the 



Inclination of the Memhrane. 29 

most varied alterations, reflections are also sometimes 
found in normal ears, upon other portions of tlie mem- 
brane. Sometimes, for instance, tliere is a faint lustre 
upon tlie posterior upper portion (V. Troltsch), and, now 
and then, a small light spot in the depression already 
described, in front of and above the short process. 

The inclination of the membrane to the auditory 
passage has a great influence on our estimate of its 
condition, and we must speak of it somewhat more 
in detail. On account of this inclination, the patholog- 
ical changes in the membrane do not appear in their 
actual form. First of all, it must be remembered that 
in inspection we do not look uj)on the membrane ver- 
tically ; and further, that its various portions, on account 
of their different degrees of curvature, have not the 
same inclination to the auditory canal. Our judgment of 
the degree of this inclination, derived from inspection, is 
very uncertain, for we estimate it much less than it 
proves to be in the anatomical preparation. 

The marked inclination of the membrana tympani, in 
the first place, affects our judgment of its superficial 
area. On account of the obliquity of its plane to our 
axis of vision, it appears smaller on inspection than it is 
in reality, being seen in perspective. The less the incli- 
nation, — and, according^ to the f oregoino^ statements, there 
are differences here very frequently, — the larger the 
membrana tympani appears to us, in case a large part of 
its anterior portion is not hidden by a too great curving 
backward of the anterior osseous wall of the meatus. In 
cases where the meatus is wider and short, the membrane 



30 Membrana Tymj^anL 

appears larger. Such is tlie difficulty of determining 
by inspection tlie proper form of tlie membrane, in con- 
sequence of its inclination; and to this difficulty the 
aforesaid relation of the anterior wall of the osseous 
canal also contributes. Hence it follows that patJiolog- 
ical alterations of the membrane must, on account of 
its inclination, also undergo an apparent change in form 
and size. This, in many cases, as will be seen hereafter, 
is clearly proved on dissection. 

In like manner the curvature of the membrane, as 
well as the inclination, to which it stands in intimate 
relation, has an influence in the diagnosis of the patho- 
logical condition. It is well known that the membrana 
tympani, through traction of the manubrium, is externally 
concave ; but this is only true of the membrane as a whole. 
From the deepest point of its concavity, the so-called 
umbo, going toward the periphery, it has an external con- 
vexity as already stated. The reason of this is a purely 
physical one, since we see the same phenomenon upon any 
elastic membrane which is strongly bellied out by trac- 
tion or pressure on any point whatsoever of either 
side. The curvature of the membrana tympani, like its 
inclination, diifers in different individuals ; and our judg- 
ment concerning its degree is in like manner defective. 
Just as the membrane appears to us to stand more verti- 
cally than is real, so it appears to have a less degree of 
inward curvature. We generally judge of the more or 
less pronounced curvature of the membrana tympani by 
the position of the handle of the malleus ; yet this 
as will be seen in the sequel, is not a criterion in every 



Curvature. 31 

case. The external convexity, as we pass from the umbo 
toward the circumference, is not the same upon all parts 
of the membrane, but is somewhat greater in the anterior 
lower quadrant and its vicinity than upon the j)osterior 
portions. That no regular curvature can occur here, 
follows from the fact that the membrana tympani is not 
circular, and that the end of the manubrium, as stated, 
is not found at the centre of the membrane. These 
differences and irregularities of curvature in different 
individuals can best be estimated from the variations 
already mentioned in the form of the cone of light as they 
present themselves in persons with normal hearing. 

It remains, still, to mention an appearance referable 
to the inclination and curvature of the membrane, which 
deserves full attention in the examination of patients. 
It is the somewhat more marked projection of the manu- 
brium into the cavity of the tympanum, combined with 
a greater bulging forward of the parts lying behind it, 
which in many cases, on account of the oblique position 
of the membrane, so cover the handle that none of it, or 
only its ends, can be seen. 

If we sum up the foregoing statements, the following is a 
brief synopsis of the normal condition (PL 1, Figs. 1, 2, 3, 
4,). At the anterior upper edge of the membrane, we see 
a whitish prominent point, the short process of the mal- 
leus ; extending from this do^^aiward and backward nearly 
to the centre of the membrane, a whitish or pale yellow 
stripe, the malleus handle, Avidening out at its lower end 
into the form of a spatula. In front of and below the 
end of the manubrium we see a trianmilar reflection, the 



32 Membrana Tyvvpani. 

cone of liglit, its point at the umbo, its base turned for- 
ward and downward toward the periphery ; the anterior 
portions of the membrane, lying between the manu- 
brium and the cone of light, generally of a darker gray 
and seldom visible as far as the periphery ; the portion 
behind the manubrium more or less distinctly separated 
from the posterior upj)er wall of the meatus by a lighter 
line, and appearing much larger and lighter, and its color 
modified in the manner stated, by the promontory and 
sometimes by the long shank of the incus shining through 
the membrane, and by the pocket of Troltsch with the 
chorda tympani. 



ANOMALIES 

IN THE TEANSPAEENCY AND COLOE OF THE 
MEMBEANA TYMPANI 



The patliological changes in the trmisjxtrency and 
color of tlie membrana tympani are manifold and very 
frequent, and often furnisli valuable data for a diag- 
nosis. The anatomical arrangement of the several lay- 
ers has already been adduced as the cause of their 
frequent occurrence. For affections, both of the ex- 
ternal meatus and of the lining of the cavity of the 
tympanum, are transmitted to the corresponding super- 
ficial layers of the membrane, making it the seat of 
appearances which come under observation the more fre- 
quently, because the diseases of the external and middle 
ear generally furnish the most fi^equent cause for disturb- 
ance of function. 

The disturbance of nutrition in the membrane 
appearing in the form of an opacity can, therefore, gen- 
erally be considered only as one sign of a process still 
going on, or the result of one that has already run its 
course. But the peculiar characteristics of opacities 



34 Meinbrana Tymjpani. 

cannot always be traced to a definite canse. For if 
we examine a large number of persons of normal hear- 
ing, we shall meet with a great variety of membranes, 
from the very rare glassy transparent to the normally 
translucent or entirely opaque. Of persons having 
normal hearing, a certain proportion, perhaps twenty- 
five per cent., have normal membranse tympani. This 
fact must be borne in mind, if we form a just estimate 
of the diagnostic value of the opacities occurring in dis- 
eases of the ear. 

The causes of opacities in persons of normal hear- 
ing are various. These changes, which we will soon 
take account of in the special description of opaci- 
ties of the membrane, must sometimes, in the absence 
of any positive evidence, be referred to anomalies 
of conformation, or to an arrest of development. The 
latter is the case when the membrane, which is nor- 
mally dull in the new-born and in childhood, does 
not clear up, as is usual at a later period. Likewise, 
these alterations may be the result of a morbid pro- 
cess that has run its course with comjDlete recovery. 
It is probable that the lack of transparency arising 
from opacity of the inner surface of the membrana 
tympani not unfrequently depends upon a catarrh 
of the cavity of the tymjDanum, which has passed 
away, leaving opacity of the mucous layer of the 
membrane, but no imj)airment of function. 

Although, in the following description, we adhere by 
preference to the anatomical arrangement, according to 
the situation of the opacity in the several layers of the 



General Opacities, 35 

membrane, still, it will easily be seen, from what lias 
preceded, that such an arrangement cannot be strictly 
adhered to, because the lamellae, so intimately bound 
together by the manifold nutritive relations, can scarcely 
be thought of as separate, and consequently, also, each 
individual layer must necessarily share in the derange- 
ment of the nutrition of its neighbor. Hence, in 
order to determine the diagnostic value of opacities, 
we must pay strict attention not only to their ana- 
tomical relations, but to their causes. From the hind 
and degree of opacity alone, a conclusion can scarce- 
ly be drawn concerning the nature of the lesion. 
Therefore the union of the anatomical with the eti- 
ological view is indispensable for a systematic ex- 
position of ojDacities of the membrane. A conclu- 
sion from them concerning the degree of functional dis- 
tui'bance is hardly ever possible. 

We now pass to the special description of opacities of 
the membrana tympani, retaining the division into two 
large groups; namely, general and circumscrihed opa- 
cities. 

A. Ge]^eral Opacities. 
The variety of colors exhibited by general opacities 
are of little importance in diagnosis, since, even in 
affections of the same layer, they frequently present 
very different shades. We have already stated that, 
in the illumination of the membrana tympani, its 
color is a combination of the peculiar colors of the 
membrane, of the rays reflected from the promontory, 



36 Memhrana Tympani. 

and of the kind of light employed. Now, in fully 
developed opacity, the transit of light through the 
membrane is reduced to a minimum, and consequently 
also the amount reflected from the promontory is ex- 
tremely small, so that it can scarcely be regarded as 
a factor in the color. The proper color of the mem- 
brane is lost by the de230sit in or upon it of an opaque 
substance, and hence the membrane will present the 
color peculiar to the opacity. In their causes, gen- 
eral opacities diiffer from each other essentially, and, 
according to the anatomical arrangement, are dependent, 
sometimes primarily, sometimes through transplantation, 
upon — 

1. Softening or thickening of tlie epidermic layer of 
the memhrane, 

2. Diseases of its dermoid layer. 

3. Lach of transparency in the substantia p^ropria. 

4. Opacities and thickening of the mucous layer, 

1. — Opacities of the Epidermic Layer of the Memhrana 

Tympani. 

Softening of the epidermic layer of the membrana 
tympani is very frequent, as well in its own j)rimary 
affections as in those of the external and middle ear. In 
the normal condition, as we have already stated, the 
epidermis of the membrane, like that at the points of 
transition from skin to mucous membrane, is comj)osed 
of a thin stratum of delicate, transparent epithelial cells, 
which in the deeper layers have the character of the soft 



Softening and Tliichening of the Epidermis. 37 

mucous cells of tlie rete malpigliii. As in the cadaver 
this stratum becomes clouded and opaque through macera- 
tion, in like manner during life it becomes softened by 
disease. The individual cells thereby lose their trans- 
parency, and, in consequence, the surface of the membrane 
becomes lustreless and dull. This softening is not 
uncommon in persons of normal hearing ; and while we 
admit that, in many such cases, external circumstances 
are not without an influence in the too great hardening 
and softening of the epidermic tissue, still we must, on 
the other hand, bear in mind the fact, that shining trans- 
parent membranes are met with in persons having wide, 
straight, and short auditory passages, which make the 
inspection of the membrana tympani possible without 
any kind of illumination, and appear especially exposed 
to wind and dust. In pathological conditions, a soften- 
ing of this kind is generally the result of a serous exu- 
dation from the membrana tympani, as it occurs in the 
beginning of acute catarrh of the cavity of the tym- 
panum, in the rare forms of idiopathic myringitis, and 
at the outset of otitis externa. 

Abnornal tliickening of the epidermic layer is to be 
distinguished from simple softening. It very rarely 
occurs independently, but is usually a sign in part of 
pathological processes in the external meatus, which 
have been transmitted to the external layer of the 
membrane, and are due. to fi-equently recurring hyper- 
semise, and to past or existing catarrhs of the external 
meatus. A marked hypertrophy of the epidermis is 
often seen diuing the recession of purulent catarrh of 



38 Memhrana Tymjpani. 

the middle ear wliicli has resulted in perforation of the 
membrane. 

Thickening of the ej)idermis in consequence of conges- 
tions of the external auditory canal is not unfrequently 
observed in frost-bites of the external ear, in cases of 
fi'equently recurring furuncles of the meatus, in eczema 
and erysipelas. Here, as in hypersemise of the skin, 
an increased formation of epidermis takes place, the 
meatus either appears partially filled Avith epidermic 
scales and cerumen, or is covered by a continuous, often 
stratified layer of thickened epidermis, which may be 
removed in large membranif orm plates, or as a coherent 
cul-de-sac. 

After a catarrh of the external meatus has passed off, 
the excessive formation of epidermis usually continues 
for a time. Its growth is so rapid, that, even in a 
single day after its removal, a new layer has formed in 
the meatus and upon the membrana tympani. 

The opacities of the membrane from thickening of the 
epidermic layer differ according to its density, and the 
admixture of fatty particles, or of dried pus and mucus. 
For distinguishing them fi^om opacities arising from 
thickening of the mucous membrane, we possess a sign, 
usually of value, in the clearness with which the manu- 
brium and short process are seen. The most marked 
opacity of the mucous membrane very rarety excludes a 
view of these portions of the malleus ; whilst, indeed, 
with a very slight degree of epidermal thickening, the 
manubrium is very indistinct, and, in case of congested 
vessels, is of a dirty orange color, as seen through the 



Epidermal Thickening, 39 

layer. In more marked tliickeniug it cannot be seen 
at all. The sliort process, however, is sometimes still 
recognizable, even with a somewhat greater deposit. 
The color of the deposit is usually grayish-white or 
dirty yellow, or here and there light or dark brown 
fi'om the admixture of particles of cerumen. The mem. 
brane has lost its normal lustre, though at several points 
it may glisten with fat, or indeed throughout in case the 
epidermic cells are filled with it. *As might be sup- 
posed, deviations in the curvature of the visible sur- 
face of the membrane are also associated with these de- 
posits ; and we find it either flattened or uneven and 
rough, and the boundary between the meatus and the 
membrane can no longer be distinguished. 

The epidermic deposits seldom afect the hearing when 
the stratum is thin, but there are marked exceptions 
to this rule. Thicker strata however, especially when 
closely adherent to the dermis, by reducing the suscepti- 
bility of motion in the membrana tympani, will now and 
then occasion a high degree of deafness, and sometimes 
tinnitus aimimi^ which is speedily relieved by removal 
of the e]3idermis. However little influence such deposits 
may seem to have in the disturbance of function, still the 
importance of a knowledge of these facts appears in 
practice ; for cases often come under observation in 
which the deafness and tinnitus aurium thus occasioned 
have been treated by the most varied and often strange 
methods, though they are speedily relieved by first drop- 
ping in some glycerine, and then syringing with luke- 
warm water. 



40 Memhrana Tynvpani, 



2. — Opacities from Diseases of the Dermoid Layer 
of the Memhrana Tympani. 

To what we have already said, in the description 
of the microscopic anatomy of the membrane, concern- 
ing the texture of the dermoid layer, we must further 
add that the vascular twigs of the membrana tymj)ani 
are invisible in the normal condition, notwithstanding 
their manifold ramifications and anastomoses. When 
somewhat congested however, the wide-spread vascular- 
ity is at once apparent, and hypersemiae of a higher 
degree may cause an opacity of the membrane, even 
without the occurrence of any change of structure. 
Congestion of the cutis of the membrana tympani not 
unfrequently occurs simultaneously with hypersemic 
conditions of the external meatus, and of the cavity of 
the tympanum. In the normal condition, also, con- 
gestion limited to the membrane may be excited by 
mechanical influences, such as too frequent touching 
of the membrane, long-continued examination with the 
speculum and mirror (Troltsch), and frequent irritation 
of the external meatus by hard substances. This, how- 
ever, disappears after a time. 

Congestion of the vessels of the handle of the malleus 
is very conspicuous in the examination of hyperaemic 
membranse tympani, a clear red, or livid vascular 
bundle (PL 1, Fig. 3) extending along the posterior 
edo:e of the handle as far as its lower end. At the 
upper end, it either terminates or is continuous with 



Congestions of the Dermoid Layer. 41 

tlie congested vessels of tlie upper wall of tlie external 
meatus, at its point of union witli tlie membrane. We 
often see, esjDecially in acute catarrh of tlie cavity of tlie 
tympanum, a more or less defined liypersemia at tlie 
upper edge of the membrana tympani, with a diameter 
of fi'om two to three lines, affecting partly the 
membrane, and partly the meatus, and having in its 
midst the yellowish projecting short process, not unlike 
an acne pustule surrounded by a red areola. In one 
case, a small, sharply defined stripe of vessels stretched 
along the upper wall of the meatus beginning at its 
middle, and extended to the end of the manubrium, as 
its vascular bundle. In examining aural patients, we 
find a great variety in the appearance of the ves- 
sels of the manubrium, especially in chronic catarrh, 
without purulent secretion. In several such cases 
I have seen a permanent congestion of these vessels, 
sometimes so considerable that it entirely covered 
the handle of the malleus (PL 2, Fig. 4), so that 
its direction even could only be recognized by means of 
the injected vessels. In other cases, on the contrary, 
the injection was less. I have frequently seen the 
handle entirely surrounded by a little pink vessel, or 
crossed obliquely by a larger one ; the latter I have also 
sometimes seen after the subsidence of otorrhoeas with 
formation of cicatrices or of calcareous deposits in the 
membrane. 

The intermittent congestions of the manubrium are 
worthy of notice, both in chronic affections of the tym- 
panic ca^dty and in those persons whose hearing is 



42 Memhrana Tympani, 

otlierwise normal, but ttIio, at times, tlirougli conges- 
tions of tlie brain and of tlie oro^ans of hearino- are troub- 
led with tinnitus anriiim ,mental confusion, and attacks 
of vertigo, witli tlie cessation of wliicli tlie injection at 
tlie manubrium also disappears. 

AVe are indebted to the pioneer labors of Von Troltscli 
for a knoTrledo^e of tlie more intimate relations of tlie 
vessels of the external meatus to those of the dermoid 
layer of the membrana tympani. Indeed, the examina- 
tion of aui*al patients, in whom the vascular ramifications 
are often plainly visible, is best calculated to convince 
us of the correctness of this author's views. 

Besides the congestion of the vessels of the manu- 
brium, which at once catches the eye, we may, in ex- 
tensile congestions of the membrane, discover a cii'cular 
^vL'eath of vessels near its peripheiy, fi'om which little 
converging branches run toward the centre of the mem- 
brane to anastomose with the vessels of the manubrium 
(PL 1, Fig. 5). Especially in acute catarrh of the tym- 
panic cavity, or in relapses of chi'onic catarrh, these 
relations are prominent ; and thought hey ai'e not alone 
sufficient to determine the locality of a morbid process, 
yet the diagnostic value of such a condition, taken 
with the other symptoms, is not to be underrated. 

Case : Acute Catarrh of the Middle Ear — Regular Course — 

Recovery. 

Mr. A., Student of Medicine, in the month of June of the present 
year, shortly after a cold bath, experienced a seyere pain in the 
right ear, with which a loud ringing was soon associated. An ex- 
aminatioD, made the following day, revealed a uniform pink injec- 



Congestions of the Dermoid Layer. 43 

tion of the external meatus, especially in its osseous portion, the 
redness being more intense at its junction with the membrana tym- 
pani. This was marked at the anterior upper quadrant, near the 
short process, which, as a yellowish-white tubercle, was in strong 
contrast to its dark red surrounding. Along the manubrium ex- 
tended a dark red bundle of vessels, so strongly developed as to 
make the handle itself invisible. Xear the periphery of the membrane 
a circular wreath of vessels could be seen, from which small, slightly 
serpentine branches extended to the centre to anastomose with the 
vessels of the manubrium. The remaining portions of the mem- 
brane, lying betw^een the injected parts, were dirty gray or lead 
colored (Yon Troltsch), and dotted with serous exudation. The 
light spot was dimmed, and scarcely visible. The hearing distance 
was not mucb affected. On account of the continued severe pain, 
five leeches were applied close in front of the tragus, and a gargle 
ordered, of Tr. Opii 5 ss., Aq. Font. 3 iv., with a little sugar. On 
the following day the pain had entirely left the right side, but had 
attacked the hitherto unaffected left ear, with the same severity and 
just the same appearances of the membrane as were upon the other 
side. Five leeches were now also applied upon the left side^ and 
upon their falling off the pain immediately abated. On the third 
day of the attack, the pain on both sides had disappeared, but the 
ringing in both ears continued, and the hearing distance for the 
watch had fallen to about three or four inches on either side (the 
mean normal distance being twelve feet) ; for conversation it had 
fallen to somewhat more than six feet, and the condition of the 
membrane was nearly the same as on the previous day. After mak- 
ing both Eustachian tubes pervious, simultaneously, by means of the 
air-douche, according to the method devised by me, the hearing dis- 
tance for conversation immediately rose on the right side to twenty- 
one feet, and to forty-two on the left ; the ringing was less, and the 
patient felt in all respects nxuch relieved. On the fourth day of the 
attack the condition of the membranes was the same, except that 
they did not appear so moist. The hearing distance had sunk again 
to twelve feet, probably on account of the reaccumulation of mucus 



44 Memhrana Tymjpani. 

in the cavity of the tympanum, but rose to the height of yes- 
terday, after the employment of the air-douche. Upon the fifth day 
a considerable abatement of the injection of the external meatus and 
of the peripheral wreath of vessels was already apparent. Only the 
vessels of the malleus were still injected, and several small branches 
extended from the centre toward the circumference, which were 
sharply defined upon the dull, greenish-yellow membranes. The 
lustre of the membranes was entirely wanting. The hearing dis- 
tance had decreased but little since the day before, and rose to 
fifty-four feet, for conversation, on the right side ; on the left to 
forty-eight, and to three feet for the watch. During the three days 
following, the condition of the membrane, as well as the hearing dis- 
tance, remained the same. Upon the ninth day of the disease there 
was no trace of injection in the meatus, and upon the membrane 
only a pale red bundle of vessels could be seen along the manu- 
brium. The cone of light was present, although dull and somewhat 
faded, and the membrane was of a dull gray. The hearing distance 
was nearly normal, and the ringing had entirely ceased. The 
air-douche was continued daily. Upon the thirteenth day, all 
the morbid appearances of the membrane had gone. The lustre and 
curvature, as well as the hearing distance, were perfectly normal. I 
had an opportunity of verifying this again by an examination some 
months later. 

This is nearly a typical case of acute catarrh of the 
middle ear, with predorainantly mucous secretion from 
the mucous membrane of the cavity, running a favor- 
able course and resulting in recovery. The examination 
of numerous cases, however, abundantly proves that 
sometimes there is a different condition of the membrana 
tympani : such as abnormal external convexity, general 
or circumscribed ; vesicles formed by separation of cer- 
tain portions of the epidermis through serous effusion; 
and before or behind the manubrium a circumscribed 



JEccJiymoses. 45 

greenish-yellow discoloration of tlie elsewhere in- 
jected membrane. Entirely similar conditions of the 
membrane may also exist in purulent catarrh of the 
middle ear for days, indeed for weeks, before the mem- 
brane is perforated by the accumulation of pus in the 
cavity. Therefore, in the first stages of the disease we 
can never accurately decide whether a simple or a puru- 
lent catarrh will be developed. 

Next to the congestions of the membrana tympani 
we place its eccJiymoses, They likewise occur in acute 
catarrh of the middle ear, in inflammations of the mem- 
brane, or in acute relapses of chronic catarrh. Although 
occurring in otherwise perfectly healthy individuals, yet 
they are more frequently observed in broken-down, 
decrepit subjects. In a case of marasmus after typhus, 
where, in the last stages, an acute catarrh came on with 
tinnitus aurium, besides small scattered ecchymoses in 
the membrana tympani, exactly similar ones were found 
in the mucous membrane of the cavity, especially 
upon the promontory. The recognition of ecchymoses 
of the membrane by inspection is very easy. We see, 
usually upon a more or less congested membrane (PL 1, 
Fig. 6), irregular hemorrhagic spots, in varying numbers, 
sometimes sharply defined, sometimes faint, and especially 
frequent behind the manubrium or lying partially upon 
it. Not unfrequently, similar ecchymoses are found in 
the osseous meatus ; sometimes, a large patch upon its 
upper wall, which, as we once observed in case of an 
old woman, at the beginning of an inflammation of the 
membrana tympani, passed over upon the membrane 



46 Memhrana Tynvpani, 

witliout interruption and covered its upper half. We 
seldom find such little ecchymoses in a chronically in- 
flamed and secreting membrane, either with or without 
perforation. 

Case : Acute Catarrh of the Middle Ear — Symmetrical Ecchy- 
moses before aiid behind the Manubrium of each Ear — Recovery. 

Mr. S., a provincial judge, set. 46, upon the day following a vapor 
bath, in which some water entered his ears during the douche, 
experienced a severe stinging paiu in the right ear, which yielded 
immediately after dropping in some lukewarm oil, but gave place 
on this side to considerable difficulty of hearing. Upon the follow- 
ing day, the same symptoms presented themselves in the left ear. 
Examination showed the right external meatus here aud there red- 
dened, the manubrium partially covered by injected vessels, the 
short process clearly visible, and half a line behind the manubrium, 
and the same distance from the posterior periphery of the mem- 
brane, a pretty sharply defined, dark red ecchyraosis, two and a half 
to three lines in diameter ; in front of the manubrium, an exactly 
similar ecchymosis, only somewhat smaller. Inspection revealed a 
like condition of the left ear. The watch could be heard on the 
right side only upon contact ; on the left, at the distance of three 
inches. Conversation could be understood on the right side, at the 
distance of four feet, but at more than six upon the left. Sound was 
transmitted by the bones upon both sides. After treatment by my 
method for opening the Eustachian tubes, the hearing distance rose 
on both sides to eighteen feet. Upon the next day the hearing dis- 
tance had indeed fallen somewhat, but upon repetition of the treat- 
ment, in like manner rose again to twenty-one or twenty-four 
feet. This treatment was continued for three weeks. During this 
time, with constant increase of the hearing distance, both for the 
watch and for conversation, the ecchymoses in the membrane visibly 
decreased from day to day ; then a rusty discoloration came on, and 
finally they disappeared entirely. The lustre of the membrane again 



Interstitial Exudation, 47 

appeared, as also did the manubrium and short process ; but upon 
both sides, after complete restoration to normal hearing^ there still 
remained, both in front of and behind the manubrium, grayish 
white patches of interstitial exudation, not sharply defined — the 
relics of an affection of the membrane associated with catarrh of the 
cavity. 

In still liiglier grades of acute catarrh, especially 
when accompanied by purulent secretion, the membrana 
tympani, before perforation, sometimes appears so red- 
dened, that individual ramifications of vessels can no Ions;- 
er be distinguished. Much oftener we find a uniformly 
injected surface, with no portion of. the malleus recog- 
nizable, and we see this redness at the same time extend- 
ing over a large part of the osseous canal. 

Upon the injected membrana tympani, in acute 
catarrh of the middle ear with purulent secretion, in 
many cases, previous to the perforation we see at one or 
more points, especially often at the posterior lower part, 
greenish-yellow spots, some lines in diameter, usually 
faded at the circumference. These are caused by inter- 
stitial exudation in the membrane, which by pressure 
upon the vascular branches probably causes the disap- 
pearance of the congestion at these points. In one case, 
after perforation, I saw the aperture exactly at the 
point where the aforesaid yellow discoloration was pre- 
viously seen. 

The opacities arising from inflammation differ accord- 
ing to the degree of congestion, and its products in the 
dermoid and other layers. The dermoid layer has, for 
instance, in common with the lining of the osseous canal. 



48 Membrana Tynvpani. 

the peculiarity of assuming, in its inflammations, the 
characteristics of mucous membranes similarly affected. 
As we have stated, it is very thin normally ; but in in- 
flammation it may become much swollen and thickened. 
We often find, in the cadavers of those who have 
been affected with otorrhoea, an intact or a per- 
forated membrana tympani, from a half to three-quar- 
ters or a line in thickness, in which the greater part of 
the thickening is to be referred to swelling of the der- 
mis; a smaller portion to the simultaneous interstitial 
exudation in the substantia propria. In the microscopic 
examination of a cutis thus changed, exudation in the 
form of detritus and pus-corpuscles is sometimes visible 
in the midst of the meshes of loose connective tissue and 
the numerous varicose vessels. As might be su]3posed, 
even the slightest thickening of the cuticular layer will 
materially affect the transparency of the membrane, yet 
the changes thus caused in the original aspect of the dis- 
eased object present some differences worthy of notice. 

In acute inflammations of the external layer of the 
membrane, and indeed in its chronic secondary inflam- 
mations, the line of demarcation between the meatus 
and the membrane is ill defined, on account of consider- 
able swelling of the lining of the meatus. The super- 
ficial area of the membrane appears considerably dimin- 
ished, more or less reddened by strongly injected ves- 
sels, and spotted with pus (PL 1, Fig. 8), or a flocculent 
exudation (PL 1, Fig. 9). The membrana tympani is 
thus abnormally flattened, or rendered uneven as if gran- 
ulated, and the light thrown in is reflected, at one or 



Opacities of the Dermoid Layer — Continued, 49 

more places, from small circumscribed points, wliicli, even 
in impei-forate membranes, show a pulsation. In slighter 
degrees of congestion, liowever, tlie membrane will, ac- 
cording to tlie amount of exudation in its dermoid layer, 
appear orange-colored, in part also dirty grayish-yellow, 
often party-colored, and a distinction between the indi- 
vidual portions of the membrane will be rendered impossi- 
ble. But all the opacities of this layer which are caused 
by swelling have the common characteristic of com- 
pletely hiding the malleus handle in most cases, in- 
asmuch as it lies behind the dermis. The short pro- 
cess is likewise invisible in great swelling; but in 
less degrees is often distinctly prominent as a red- 
dish or yellow tubercle. Only in two cases was the 
malleus handle with its short process clearly distin- 
guishable in the presence of inflammatory softening of 
the dermoid layer of the membrane. 

The swellings of the dermoid layer, if not accompa- 
nied by perforation of the membrane, run a comparatively 
favorable course ; for, though they often cause an opacity 
of the substantia propria which cannot be removed, still 
as often it returns to an entirely normal condition, 
no chanore of structure remaininof. At first, in such 
cases, the congestion gradually disappears, the secre- 
tion upon the surface becomes less, and the mem- 
brana tympani. appears not unlike a layer of false 
membrane, of a grayish-yellow or pale yellow col- 
or. While the swelling is subsiding we see, first, the 
short process gradually coming into view ; but the 
malleus handle usually first appears after complete sub- 



50 Memhrana Tymjpani. 

sidence of the swelling and the termination of abnormal 
desquamation, visible through the clear or somewhat 
dull gray dermis. The apj)earance of the manubrium 
is therefore usually to be regarded as a favorable sign. 
If, after the termination of inflammatory processes, 
circumscribed opacities remain here and there in the 
dermoid layer, they are connected, as we shall see, with 
changes in the substantia propria. 

3. — Opacities froin Changes in the Substantia Propria, 

The general opacities of the membrana tympani de- 
pendent on lack of transparency in the substantia pro- 
pria arise either by immediate transmission from the 
other layers of the membrane, or are secondary to affec- 
tions of the deeper lying structures of the ear ; and 
they also occur independently in old age. Only the 
last two kinds of these processes are limited to the 
substantia propria. The first are generally associated 
with affections of the dermoid and mucous layers, and 
are complicated by their opacities. Concerning the na- 
ture of the ^pathological changes in the substantia pro- 
pria, there are at present only very incomplete investiga- 
tions, although the most recent reports of post-mortem 
examinations have thrown some light upon the nature 
of the primary, as well as of the secondary opacities of 
this layer. 

The opacities of the substantia propria do not always 
arise from an exudation poured into it from the vessels 
of the neighboring layers, for careful examination of the 



Opacities of the Substantia Propria. 51 

patliological anatomy reveals essential diiferences in 
their character, thoiigh they are commonly recognizable 
only as a lack of transparency, and during life, for want 
of definite diagnostic points, cannot always be distin- 
guished fi'om opacities of the inner layer of the mem- 
brane. Though the changes which appear in the sub- 
stantia propria are especially marked in the circumscribed 
opacities, yet also in the general opacities we usually 
find products, recognizable by the microscope, explaining 
the lack of transparency. It must, however, be admit- 
ted, that in many cases of marked general opacity which 
had been observed during life, where both dermoid and 
mucous layers were found unaltered, in the substantia 
propria also, no change accounting for the opacity could 
be discovered by means of the microscope. In the 
yellowish, clouded membrange tympani of an old man, 
somewhat hard of hearing, the dermis and mucous mem- 
brane, on isolation of the individual layers, appeared 
of normal character, whilst the substantia propria was 
considerably hypertrophic d in its fibrous structure, analo- 
gous to the condition of the membrane described by 
Toynbee as " fibrous lamina thickened ; " and on micro- 
scopic examination we were unable to discover anything 
abnormal besides the fibres of the membrane. 

When Toynbee, in his descriptions of diseases of 
the membrana tympani, speaks of an inflammation of 
the substantia propria^ we can, on account of the above- 
mentioned anatomical conditions, agree mth him only 
when a secondary process in the substantia propria is 
meant. For simultaneously with this process, in which 



52 Membrana TymjpanL 

lie describes tlie membrana tympani as yellow and tliick- 
ened, Toynbee found adhesions between tlie membrane 
and otlier portions of the cavity of the tympanum. 
Here, therefore, the admission of a secondary exuda- 
tion into the fibrous tissue, as the result of inflammation 
of the mucous layer, appears justifiable. It is, moreover, 
probable that a parenchymatous process, primary in the 
sense of Virchow, may exist in the substantia propria. 
This opinion, however, still needs proof. 

On examination, the exudations into the substantia 
propria, secondary to inflammations of the dermoid and 
mucous layers, present some differences, according to the 
stage of the process. If we have an opportunity in acute 
cases — for instance, upon the cadavers of typhus patients 
in whom a purulent catarrh came on in the course of the 
disease— to examine the membrane, in such cases usually 
perforated and inflamed, we find it so swollen and mace- 
rated that an isolation of its several layers is impossible. 
The dermis exhibits the changes described in the opacities 
of that layer. Between the fibres of the substantia 
propria we find molecular detritus in great quantity and 
pus-corpuscles, concerning which, however, it is impos- 
sible to say whether they originated here, or came in the 
preparation of the section. 

In cases where, after the termination of inflammatory 
processes in the meatus or tympanic cavity, the membrana 
tympani remains opaque and thickened, it is very stiff from 
interstitial deposit, and not unlike a little thin plate of 
cartilage ; and upon section, besides thickening of the con- 
nective tissue of the dermoid and mucous layers, we find 



Opctcities of the Substantia Propria, 53 

a tliick granular exudation in tlie substantia pro- 
pria, in tlie form of a finely molecular mass. At points 
where the deposit is much firmer and thicker, the fibres 
are interrupted and partially disappear ; whilst at other, 
less thickened points, the fibrillation remains intact. In 
addition to the molecular deposit among the fibres, we 
also find it in the stelliform corpuscles of Troltsch. 
(Compare the very interesting reports of sections by V. 
Troltsch in Yirchow's Archiv. Bd. XYIII.) A similar 
condition is often presented by membranes which, after 
the subsidence of otorrhoea, are wholly or partially 
adherent to the promontory. 

Upon examination in the living subject, a mem- 
brane thus changed appears flattened, and uneven in 
consequence of several unequally clouded portions. The 
color is a dirty bluish-^^hite, like lustreless porcelain ; 
or yellow predominates, and the membrane may be com- 
pared to a lamina of leather. The malleus handle is 
usually invisible, or is only to be recognized by means 
of a bundle of dirty red vessels, whilst the short process 
often projects as a yellowish-white nodule, or sometimes, 
indeed, is entirely invisible. 

The opacities having their origin in and limited to the 
substantia propria, without affection of the dermis and 
mucous layers, may, in the majority of cases, as our 
examinations have sho^vn, be considered a chronic fatty 
degeneration of this tissue. They sometimes appear, both 
in old and in young ^persons, without impairment of 
hearing ; yet they are very marked in cases of deafness 
continuing for a long time, in consequence of anchylosis 



54 Memhrana Tympani, 

of the stapes witli the fenestra ovalis. In one case of 
this sort (Allgem. Wiener mediz. Zeitung, 1861), the 
membrana tympani appeared dull and bluish-white 
throughout. In another case, the lustre of the membrane 
was indeed present in a high degree, but its color was 
pale yellow, like parchment (Toynbee), and the anterior 
part in the Valsalvian experiment arranged itseK in 
radiating folds (PL 1. Fig. 11). 

In both cases, the examination showed little fat- 
globules, scattered or in groups, accumulating in larger 
quantity near the periphery, at the site of the annulus 
tpTipanicus. 

4. — OjMcities f 7' 0771 Changes in the Mucous Layer of 
the Memhmna TympanL 

The general opacities which are caused by changes 
in the mucous layer of the membrana tympani are the 
most frequent, because they often occur as indications of 
a catarrh of the cavity of the tympanum ; and this, as 
is well known, furnishes by far the greater number of 
cases of deafness that come under observation. Though 
the mucous layer is normally the thinnest stratum of the 
membrana tympani, yet, even in slight degrees of swell- 
ing and softening, it may occasion considerable opacity 
of the whole membrane. It may, however, in hyper- 
trophy, become more than four times as thick as the 
normal membrane (Toynbee, V. Troltsch). On the other 
hand, dissections show that sometimes, even when marked 
opacities have been observed during life, the mucous 



^Opacities of the Mucous Layer, 55 

layer is not thickened tlirougliout, opacity of the epi- 
thelium alone being present. 

In acute catarrh of the cavity without perforation, 
the membrana tympani has a bluish-red color, on account 
of congestion of its mucous layer. From opacity of the 
more or less sympathetically afected substantia propria, 
and simultaneous congestion of the dermis, this color 
undergoes many modifications, from the dirty ash-gray to 
a dark gray with a tinge of violet. The membrane 
sometimes presents a peculiar appearance in the first 
stages of an acute catarrh of the cavity, or of acute my- 
ringitis. It is, namely, very glistening, and this lustre of 
the external layer gives to the uniformly reddened mem- 
brane the appearance of a polished plate of copper. 
This condition does not long continue, for the lustre dis- 
appears after a day or two, the membrane becoming dull 
fi'om softening of its epidermic layer, and sometimes 
divided by fissuring into irregular areas, as if covered 
with a Avhite frost. After some days it becomes clear 
again, its lustre returns, and the invisible handle of the 
malleus and short process again come to view. 

In chronic cases — and these are the most frequent — • 
we seldom find congestion of the membrane, though the 
vessels of the manubrium are sometimes injected. 
The membrane is either bluish- white, with a tendinous 
opacity, or dirty gray, and usually dull. The cone of 
light is dimmed, as if striped ; or the membrane has not 
lost its lustre, and through opacity of the mucous layer 
has the appearance of glass, ground dull or covered with 
vapor upon one side. The manubrium is generally visi- 



56 Membrana Tympani. • 

ble, iuasmucli as it lies in front of the opaque layer. In 
some cases, however, it is either invisible, in consequence 
of simultaneous effusion into the substantia propria en- 
veloping it, or is so strongly dra^vn inward by thicken- 
ing and subsequent retraction of the mucous membrane 
overlying the tendon of the tensor tym/pan% that it either 
appears greatly shortened by perspective (Von Troltsch), 
or, covered by the posterior portion of the membrane, 
cannot be seen at all. At the same time, the short pro- 
cess and the fold running back from it are very promi- 
nent (PL 1, Fig. 10). As already stated, the substantia 
propria and the dermis usually suffer in acute af- 
fections of the mucous layer of the membrane. This 
is also true of the chronic forms, and frequently, in uni- 
form opacity of the mucous membrane, circumscribed or 
diffuse secondary opacities modifying it are also found in 
the substantia propria. 

B. ClECUMSCRIBED OPACITIES. 

The circumscribed opacities of the membrana tympani 
are very frequently located in the substantia propria^ and, 
in many respects, are of great interest. Passing by the 
usually unimportant and easily recognized opacities, 
which have their origin in circumscribed softening of 
the. epidermic layer, we regard the consideration of the 
contemporary affections of the dermoid and mucous 
layers the more important, in a description of the cir- 
cumscribed opacities of the substantia propria, because, 
on account of its non- vascular character, these opaci- 



Circumscribed Opacities. 57 

ties, in the majority of cases, are due to pathological 
processes in the adjacent layers. With few excep- 
tions, they extend into the tissue of the external and 
inner coats. 

The origin of the circumscribed opacities of the sub- 
stantia propria maybe traced with great accuracy in a class 
of cases, and this is especially true in those forms of inflam- 
mation of the external and middle ear that are accom- 
panied by purulent secretion. Without doubt, they are 
to be regarded as the results of interstitial effusion into 
the substantia propria from the neighboring vascular 
layers. This may be proved by examination upon 
the cadaver. During life these circumscribed effusions 
cannot be perceived, so long as great vascularity and 
swelling of the dermoid layer continue. When these 
are not present, yellowish- white spots of varying extent 
appear at one or more points upon the intact or per- 
forated membrane. They are usually faint at their 
edges, and only later, when the process is ended, appear 
as dirty white or chalky spots, and for the most part 
sharply defined. Less frequently, such circumscribed ef- 
fusions, without simultaneous otorrhcea, appear in clearly 
marked, oft-recurring catarrhs of the cavity of the tym- 
panum without perforation of the membrane. They are 
usually visible as irregular, ill-defined opacities, of a 
yellowish color, differing in form from the calcareous 
and osseous deposits to be described hereafter. The 
opacities mentioned are also not to be confounded with 
those occurring in the course of chronic thickening of 
the mucous membrane of the cavity. The latter appear 



58 Membrana Tympani, 

behind tlie manubrium in crescentic form^ with the convex 
side turned toward the periphery. They are of a bluish- 
white or tendinous-gray color and ill defined. With 
edges gradually becoming clearer, they lose themselves 
in the transparent portions of the membrana tympani. 
Upon examination of several such cases, they proved to 
be deposits of fat-globules and finely granular matter 
between the fibres of the membrane. 

Calcareous deposits in the membrana tympani are 
by no means infrequent, and are easily recognized during 
life. The knowledge of their occurrence appears to 
be of earlier date than is generally supposed. In 
an old work by Cassebohm (Tractatus quatuor ana- 
tomici de aure humani. Halae, 1734), we find 
the description of a preparation of the membrana 
tympani of an old woman, upon which there were cal- 
careous deposits before and behind the manubrium. 
Besides our obligations to Toynbee, and to Wilde, who 
has reported more fully concerning their occurrence and 
form Avithout being able to affirm anything of their struc- 
ture, we are indebted to Von Troltsch for more accurate 
accounts of these interesting phenomena (Anatomische 
Beitrage zur Ohrenheilkunde, Virchows Archiv. Bd. 
17, und Krankh. des Ohrs, 1862). He says: ''Such cal- 
careous deposits are, for the most part, distinctly sep- 
arated from the surrounding tissue, and mth their yel- 
lowish-gray or clear, whitish appearance are not to be 
mistaken. They occur even in childhood, and are 
not at all infrequent. With the exception of a few 
cases in which the hearing was pretty good, I have hith- 



Calcareous Degeneration, 59 

erto found them only witli higli degrees of deafness : so 
tliat similar earthy processes on the membrane of the 
fenestra rotunda, or about the foot of the stapes, may 
be inferred from them. How far such calcareous 
deposits impair the hearing power, must first be estab- 
lished by the observation of cases which are not com- 
plicated with other changes in the ear, if such calcifi- 
cations ever occur entirely alone." 

Our observations in this direction, made upon the liv- 
ing and upon the cadaver, are as follows : — 

1. The calcareous deposits in the membrana tympani 
are, in the majority of cases, to be regarded as the products 
of otorrhoeas that have passed away, where the exudation 
into the substantia propria from the neighboring layers 
has undergone a chalky metamorphosis. Even in those 
cases where a former discharge from the ear cannot be 
remembered, there is, doubtless, a number to be classed 
in this group, because many people are ignorant of an 
otitis that has run its course in childhood. That such 
deposits occur in the course of chronic catarrh of the mid- 
dle ear is well kno^vn. But it can only be determined 
with certainty that such is the origin, when the formation 
of the deposit has been observed during life. So far as I 
know. Moos, of Heidelberg, was the first to observe the 
formation of calcareous deposits in the membrana tym- 
pani. This occurred in an old woman seventy years of 
age, in the course of a chronic catarrh of the middle ear, 
without secretion and perforation of the membrane. 
Since that communication I have also had an oppor- 
tunity, in two similar cases, of f ollovdng up the develop- 



60 



Memhrana Tymjpani. 




ment of these deposits. Schwartze also observed their 
increase in several cases. 

2. During the examination of a very large number of 
persons of normal hearing^ in several cases I met with 
calcareous deposits in the membranes, such as are found 
after old otorrhoeas. 

Fig. 1 of the accompanying sketches (PI. II., Fig. 9) 
is an illustration of the right membrana tympani of Mr. 
E — ch, a student, on which a large 
crescentic, chalky white deposit is to 
be seen in front of the manubrium, be- 
hind it a smaller, irregular, polygonal 
one, which strongly contrast with the 
bluish gray color of the other parts of 
the membrane. Several oblong reflec- 
tions of light are seen at the lower end of the manubrium. 
According to his own and his mother's statement, no 
affection of his ear had ever been noticed. The hearing 
distance upon this side is, indeed, somewhat less for the 
watch than upon the left, but for speech it is just as good. 
Even more interesting is the condition of the membrana 
tympani in Mr. M — r, a student. We saw there, upon 
both sides of the manubrium, both before and behind, 
equally large, crescentic, glistening white calcareous 
deposits, with an otherwise normal appearance of the 
membrane. Nothing was known by himself or his 
parents of the occurrence of any former disease in the 
ear, and he possesses, together with a pretty good hear- 
ing distance for the watch, not only a sharp, but also 
finely cultivated musical ear. 



Calcareous Degeneration, 



61 




Fig. 2. 



Fig. 2 is taken from tlie cadaver of a person whom 
I examined during life, at the clinic of Prof. Oppol- 
zer, and who, I was obliged to say, 
had normal hearing. In the mi- 
croscopic examination of this prepa- 
ration, I found just such changes as 
I shall speak of as resulting from a 
pathological process. In the cases 
just mentioned, nothing can be said 
with certainty concerning the manner in which these 
deposits originated. 

The sketches immediately following represent patho- 
logical preparations, taken from persons whom I ex- 
amined during life. 

Fig. 3 represents the inner side of the left membrana 
tympani of a girl, twenty-four years of age, who died of 
phthisis in the clinical department of 
Dr. Kolisko. In her twelfth year she 
had suffered for a short time from 
otorrhoea. Upon this side she heard 
my watch at the distance of one foot ; 
my somew^hat sonorous voice at from 
eight to ten feet sounded very hol- 
low, as if it came out of a cellar. Besides this condition 
of the membrane, no anomaly could be discovered in 
the hearing apparatus. The calcareous deposit (Fig. 
3) in front of the handle of the malleus had not only 
invaded all the layers of the membrane, but even pro- 
jected inward markedly beyond the surface of the 
mucous layer. Upon the uncalcified portions of the 




62 



Membrana TympanL 



membrane, tlie radiate and circular fibrous layers were 
seen abruptly terminating at the distance of a line fi'om 
the peri]3hery. From here to the manubrium the mem- 
brane was remarkably thin and transparent, more 
sunken than the peripheral portion, so that the bound- 
ary between the thick peripheral and thin central por- 
tions was marked by a pretty sharp line. Only at one 
point of the thin part a bundle of irregularly arranged 
radiating fibres extended, in the form of a triangle, fi'om 
the end of the manubrium toward the periphery. (See 
Yon Troltsch, 1. c.) 

Fig. 4 is a sketch of the external surface of the right 
membrana tympani of a man, seventy years of age, who 
_ died in the section of Dr. Chrastina. In 

youth he had suffered from otorrhoea for 
a long time, and had become entirely 
deaf. Besides anchylosis of all the ossi- 
cles with the walls of the tympanic cav- 
ity, there was a small thick calcareous 
mass deposited in front of the handle 
of the malleus, and behind it was a larger one. All 
the layers of the membrane were in- 
volved. Below the manubrium was 
a perforation mth cicatrized edges. 
A bridge of the tissue of the mem- 
brane still remained, dividing it into 
two parts. 

Fig. 5 represents the inner sm^ace 
of a preparation taken from the left 
ear of a man, thirty-five years of age, who died in the 




rig. 4. 




Fig. 5. 



Calcareous Degeneration, 63 

clinical department of Prof. Oppolzer, of cancerous de- 
generation of the retro-peritoneal glands. He liad suffer- 
ed fi'om otorrhoea in earliest cliildliood, and became grad- 
ually deaf upon this side. In the tymj)anic ca^dty I 
found the malleus handle and incus slightly movable, 
the stapes completely anchylosed, and the membranous 
semicircular canals remarkably atrophied. The upper 
half of the membrana tympani (PL II., Fig. 11) was 
partially ossified, and the thickness of the membrane 
thus degenerated amounted to two lines. From the larger 
calcareous mass a thin, narrow, whitish stripe extended 
along the rest of the periphery of the membrane, fi'om 
whose lower portion an opacity of the size of a pin-head, 
mounted on a pedicle, projected into the uncalcified 
part of the membrane. This part, corresponding to 
the lower haK, is clear and transparent, and not a single 
fibre of the substantia propria can be recognized upon it 
by the glass. Although it is probable that this is the 
cicatrix of an old perforation, yet I will not ventui^e to 
state it positively. 

Besides these cases I had an opportunity to examine a 
large number of calcareous deposits in membranes, which 
were for the most part obtained incidentally in post-mor- 
tems. These, as well as the large number of observations 
made during life, show how much the deposits vary in 
form, extent, location, and structure. Most frequently 
they appear in the crescentic form described, in front of, 
or behind the manubrium, or in both places at once (PL 
II., Figs. 9, 10). Less frequently they are shaped like a 
horse-shoe, and occupy the lower two-thirds of the cir- 



64 Membrana TympanL 

cumference, surrounding the handle of tlie malleus. Oc- 
casionally there are cases in which the calcareous deposits, 
especially after otorrhoea, extend from the ex'reme periph- 
ery to the handle of the malleus, and sometimes so com- 
pletely envelop the latter that only the short process is 
visible (PL II., Fig. 11). In other cases we find, either 
upon membranes otherwise nearly normal, or associated 
with circumscribed tendinous opacities or perforations, lit- 
tle isolated or grouped (PL 11. , Fig. 4) calcareous deposits, 
not always well defined, which have been formed during 
or after catarrhs of the middle ear, or primary affections 
of the membrane. 

3. The microscopic examination of the calcified por- 
tions disclosed varieties in the different cases, which 
are worthy of notice. In a series of preparations, 
where the deposit was not very thick, the dermoid layer 
was pretty easily separated from the calcified parts. 
The mucous layer was a little more adherent. In other 
cases the separation could not be accomplished, and the 
external and middle layers proved to be involved 
in the calcific process, especially when the deposit was 
of considerable thickness. The deposit consisted of an 
amorphous, finely granular mass, lying partly between 
the fibres of the membrane, and partly in the corj^uscles 
— a condition similar to that already recorded in one 
case by Von Troltsch (1. c. sect. 4). 

Besides the amorphous carbonate of lime, usually oc- 
curring in the form stated, which accumulates at 
some points in trifling amount, at others to such a de- 
gree of thickness that none of the original elements can 



Calcareous Degeneration, 65 

be discovered, I found in one of tlie above-described 
cases (Fig. 5) (PL II. Fig. 11), together with the calcare- 
ous deposit, a true osseous formation. A thin section pre- 
sented the appearance of new bone (as, for instance, that 
from the skull of a new-born child), with pretty large, 
thickly-spread corpuscles, furnished with short pro- 
cesses. I think that Prof. Hyrtl first discovered 
this anomaly in the membrana tympani of an opossum. 
In the midst of the calcified portions I once found black 
or dark brown pigment (See Toynbee, Diseases of 
the Ear, German translation by Moos of Heidelberg), 
lying in circular groups or in stripes, and it appeared 
also to be accumulated in fusiform or stellate cells. In 
addition, there were fat-globules everywhere, in vary- 
ing amount. The fibres of the membrane had undergone 
a variety of changes, in certain cases, both in the calci- 
fied portions and their \dcinity. In one case, the riband- 
like fibres of the substantia propria could be isolated, at 
points where the calcareous mass had not entirely sup- 
planted the elements of the membrane, and the individ- 
ual fibres were frequently so changed as to appear occu- 
pied throughout mth small fat-globules and puncti- 
form granules. In sections where the calcareous salt 
had been removed by the addition of acetic acid, the 
stellate corpuscles could be seen well preserved; in 
others they were either irregularly arranged and stunted, 
or upon the apparently homogeneous sui'face little 
scattered, roundish, or somewhat irregular strongly 
refracting corpuscles were brought to -light by the ad- 
dition of the acid. These had the appearance of 



66 Meif)ibrana Tympani. 

shrivelled nuclei. The chano-e in the substantia 
propria in one case was peculiar : its fibres, name- 
ly, were blended into broad homogeneous lamellae, 
which were laid one uj^on another — a condition such as 
Professor Wedl not unfrequently found in pathological 
changes of connective tissue. Moreover, the pathologi- 
cal changes are not so definitely limited as might be 
supposed from the marked border of the calcareous de- 
posit, being also found in the apparently normal por- 
tions, especially in the parts adjoining the de]30sit. 

Besides the circumscribed 023acities already mentioned, 
more or less circumscribed opacities are found affecting 
one or more spots upon the membrana tympani, both in 
its pathological and also, not unfrequently, in its normal 
condition. These vary in form as well as in extent and 
color. Very frequently we find U23on imperforate mem- 
branes, generally behind the manubrium, tendinous gray, 
oblong, and uniformly faint or striped areas, which are 
separated by either normal or slightly clouded por- 
tions — a condition such as is often met with in chronic 
catarrhs, and after otorrhoeas, but also frequently enough 
in persons of normal hearing, especially in old age. 
The seat of these circumscribed opacities is chiefly the 
substantia propria, and, next to this, the mucous layer, 
where I once found, as the cause, little circumscribed 
deposits (amorphous exudation). 

Those tendinous opacities ^vhich affect the whole 
membrane, with the exception of one or more small por- 
tions, are woriiiy of notice. The transparent parts, 
since they permit more light to pass through, appear 



Tendinous Ojpacities. 67 

darker, and therefore also far more in the background, on 
inspection, than the grayish- white opacities. An unprac- 
tised observer, disregarding this circumstance, might easily 
mistake such a transparent dark spot, sharply defined 
fi-om the light gray surrounding, for a partial retraction. 
Not unfi'equently they have an elliptical or fusiform shape 
(PL II. Fig. 5), upon the lower or posterior portions 
of the membrane, and at first glance might readily be 
taken for slit-like perforations. In one case of chronic 
thickening of the mucous membrane of the tympanic 
cavity, which caused a moderate degree of deafness, in- 
spection showed, behind the manubrium, a sharply de- 
fined, long, oval, dark spot, over three lines in length, which, 
in the midst of the elsewhere grayish-white, pearly, lus- 
trous membrane, had the appearance of a distinctly 
marked retraction. The examination of the ear of a per- 
son who died of tuberculosis proved the opinion formed 
dming his life to be incorrect, since the trans])arent spot 
mentioned was a partially circumscribed, atrophied, 
but not sunken portion of the membrane. Some- 
times several such thin sj^ots group themselves in a semi- 
circle around the lower end of the manubrium, and I 
have found this state of things in chronic catarrhs, with 
slight, but often also with high degrees of functional 
disturbance. In case of a man twenty-three years of 
age, who, according to his own account, became hard of 
hearing in his thirteenth year, the membrane of the right 
ear presented on examination a condition such as we 
have just described. The patient was entirely deaf on 
this side, and the condition was not changed after the 



68 Memhraiia Tympani, 

opening of tlie Eustachian tube. He died of phtliisis 
j)ulmonalis in Dr. Kolisko's division, and post-mortem 
examination showed opacity of the membrane — especi- 
ally in its mucous layer. In the vicinity of the umbo 
were five very transparent atrophied spots in form of a 
half circle, of which the two middle and larger were a 
lijie and a half in diameter. The manubrium projected 
strongly inward toward the promontory. The tendon of 
the tensor tympani appeared much shortened. The head 
of the malleus and the body of the incus, firmly anchy- 
losed, were adherent to the upper and outer wall of the 
tympanic cavity. The stapes was movable, though not 
so much so as in the normal state. In other respects the 
lining of the tympanum presented no anomaly worthy of 
notice. 

Circumscribed opacities in many cases ^ireperipheralj and 
are circular in form. As already mentioned, the circular 
fibres accumulate near the periphery of the membrana 
tymj^ani to such a degree that it is not only somewhat 
more rigid at this point in the normal condition, but also, 
in the majority of cases, less transparent than at other 
portions. This peripheral dulness sometimes exists in 
normal states, and in pathological conditions is often so 
plainly marked, that it is at once recognizable as a dis- 
tinct grayish-white opacity varying in breadth. (PL I. 
Fig. 12.) 

This may best be likened to the arcus senilis of the 
cornea, and sections at this point show that sometimes the 
opacity is caused simply by the de230sits of fat-globules 
between the thickly crowded peripheral circular fibres ; 



Perijylieral Opacity. 69 

wliile in otlier eases the membrane appears remarkably 
thicker and more rigid at this point, through simulta- 
neous thickening of the corresponding mucous layer. 
That in such cases the central portion of the membrana 
tymj)ani often undergoes a change of curvature, espe- 
cially inward, we will explain more in detail hereafter ; 
only be it remarked that, even where this is not the 
case, the central portion, on inspection, because more 
transparent and darker, a23pears to lie deeper than the 
dull perijDhery. 

If we submit \he fimctional disturlances accompanying 
opacities to careful clinical observation, we find, as a gen- 
eral rule, that they bear no proportion to the changes 
visible on the membrane, since, in one series of observa- 
tions, the changes are only insignificant, or may be en- 
tirely wanting, where there is a marked functional dis- 
turbance ; while, on the other hand, as is clear from what 
has been said before, extensive opacities, which at once 
strike the eye, will be observed not unfrequently in cases 
where the impairment of function is very slight, or in 
persons of perfectly normal hearing. 

As regards diagnostic value, the results of these clinical 
investigations may be summed up in the following points : 

1. Diseases of the membrana tympani are, for the most 
part, combinations of the signs of diseases of the external 
and middle, less frequently of the inner ear. 

2. Oj)acities occur frequently in aural disease, accord- 
ing to the unanimous testimony of authors, and in many 
cases afiEord important data for a diagnosis. 

3. The fact, however, that analogous opacities occur 



70 Membrana Tympani. 

also in persons witli normal hearing, diminislies tlieir 
diagnostic value not a little. Nevertheless they deserve, 
in given cases, full consideration ; since, taken in connec- 
tion mth the other signs, with the nature and course 
of the case, and the degree of functional impairment, they 
often essentially facilitate the diagnosis. 

Itard : Traite des Maladies de I'oreille et de I'audition, 1821. 

Saissy: Maladies de I'oreille, 1829. Deutsch von Fitzler. 

Lin eke : Handbncli der theoretischen u. praktischen Ohrenheil- 
kunde, 1837. 

Ran : Lebrbuch der Obrenbeilkunde, 1856. 

Wilde : Practical Observations on Aural Surgery, 1855. Deutsch 
von Haselberg. 

Toynbee: Diseases of the Ear, 1860. Deutsche Bearbeitung von 
Moos in Heidelberg. 

Kramer: Die Ohrenheilknnde der Gegenwart, 1860. 

Y. Troltsch: Anatomie des Ohrs, 1861. 

Y. Troltsch: Krankheiten des Ohrs, 1863. 

Schwartze : Praktische Beitrage zur Ohrenheilknnde, 1864. 



ANOMALIES 

IN COHERENCE AND CURVATURE OF THE 
MEMBRANA TYMPANI. 



The solutions of continuity of tlie membrana tymjaani, 
usually ievuiedi jyerforations^ very frequently come under 
observation in Aural Surgery. It is generally easy to 
recognize them, but to accurately determine tlieir size 
is very important, since, under similar conditions, tlie 
prognosis respecting recovery and tlie cicatrization of 
tlie gap in the membrane depends upon tlie extent of its 
loss of substance. 

Tlie most frequent cause of perforation is purulent 
catarrh of the middle ear. Generally, several causes 
work together in the production of ruptures in the mem- 
brane. It seems certain that every severe inflam- 
mation of the mucous membrane of the tympanic cavity, 
affecting also the mucous layer of the membrana tym- 
pani, produces a softening, such as occurs in in- 
flammation of other tissues. The secretion of pus and 
mucus in the cavity of the tympanum now becomes so 
abundant, that, as it accumulates, it exercises a strong 
pressure on the walls of the cavity, and the membrane, 



i'J^ 



Memhrana Tympani. 



softened by inflammatory action, is the more easily rap- 
tured. This commonly happens in cases of acute purulent 
catarrh of the middle ear, as it occurs in the exanthe- 
mata, in severe naso-pharyngeal catarrh, or, primarily 
also, during other maladies. In other cases, a sudden ex- 
cessive pressure of air in the cavity of the tympanum 
leads to rupture of the membrane, yet only where the 
mucous lining of the tympanum is already diseased, 
and the tissue of the membrane has suffered the change 
just indicated. We observe this not unfrequently 
in purulent catarrh of the middle ear, as it often pre- 
sents itself in cachectic, tuberculous, and scrofulous per- 
sons. The process, in these cases, usually commences with 
scarcely perceptible inflammatory symptoms, sometimes 
with only slight tinnitus aurium, or occasional pricking 
sensations in the ear, or without any subjective symp- 
tom, the first intimation that the patient has of any lesion 
of the ear being the whistling of the air through it in 
blowing the nose or sneezing, followed at once by a more 
or less copious discharge from the ear. 

If a post-mortem examination of such cases is made 
shortly after their inception (and this affection not un- 
frequently occurs in the last stages of phthisis), we gen- 
erally find the mucous membrane of the middle ear pale, 
seldom hyperaemic, and covered with a thin layer of 
creamy muco-pui^ulent secretion, and in the membrana 
tympani, usually in its lower segment, an irregular per- 
foration from a line to a line and a half in diameter, the 
border of the opening being softened and collapsed in folds. 

Far less frequently the destruction of the membrane 



Causes of Perforation, 73 

takes place in tlie opposite direction, and tliis results 
either from traumatic injuries, or from consecutive in- 
flammation of its dermoid layer. For instance, in diffuse 
inflammation of tlie external meatus, the dermoid layer 
being sympathetically affected, an inflammatory soften- 
ing of the part occurs, just as in inflammation of the 
mucous layer, and perforation may take place without 
the intervention of any fm1;her mechanical force, simply 
by the breaking do^vn of the membrane at some point, or 
by the simultaneous formation of an abscess in it ; or it 
may occur, as in the case above mentioned, in the act of 
sneezing or blowing the nose. 

Perforation may result here also from ulceration. 
Although this method of origin is alleged by Toynbee 
to be pretty frequent, yet its recognition during life is 
very difficult, I might say impossible, since it would not 
be easy to recognize on inspection, even after careful 
cleansing, a little ulcer upon a membrane swollen and 
covered with secretion, and soaked with exudation ; and 
since isolated elevations and depressions appear upon 
every inflamed membrana tympani, post-mortem exami- 
nation furnishes the only ground of belief that ulceration 
can lead to perforation. We find, for instance, though 
but rarely, in cases of long- continued otorrhoea with per- 
foration of the membrane, after careful removal of the 
secretion, one or more irregular erosions near the opening, 
which extend into the middle layer of the membrane. 
Whether such erosions, occurring where an opening is 
already found, can lead to complete j^^rfor^tion of 
the rest of the membrane, I cannot determine, since, so 



74 Memhrana Tymp^ 



am. 



far as I know, there has been no case observed where 
there were two openings in the membrane. 

We can usually be certain concerning the manner in 
which the perforation occurs only when we have observed 
the process previously to the rupture, and can accurately 
determine its locality. After mixture has taken place, 
we cannot easily determine mth certainty whether the 
perforation has originated in the cavity of the tympanum, 
in the external meatus, or in primary inflammation Avith 
abscess of the membrane. We can, in given cases, 
arrive at a probable conclusion only by comparing 
the early history of the disease, as remembered, with its 
course. Thus, it is to be inferred that the lesion had its 
origin in the cavity of the tympanum when a severe 
catarrh, or an idiopathic or exanthematous angina has 
preceded the discharge. When the history of the case is 
not clear, we can only determine what is most probable 
by the fact that the majority of otorrhoeas have their 
origin in the cavity of the tympanum. 

Although we may be convinced by a long series of ob- 
servations that rupture may take place at any point of the 
membrana tymj)ani, and loss of substance extend out 
from this, yet it appears that the perforation much more 
frequently occurs in the parts intermediate between the 
malleus handle and the annulus cartilagineus (peripheral 
ring of the membrana t}Tnpani) than at the periphery, 
or near the manubrium. The reason of this is to be 
found in the fact that the elastic elements of the substan- 
tia propria are accumulated to a much greater extent 
at the last-mentioned places, and consequently a greater 



Location and Extent of Perforations, 75 

resistance to pressure and erosion is offered here than at 
other portions of the membrane. According to Wilde, 
perforations are much more frequent in the parts lying 
in fi'ont of the manubrium, because they are most exposed 
to the pressui'e of air coming in through the Eustachian 
tube. The cases, however, are frequent enough in which 
perforations occur below or behind the manubrium. 

The size of perforations varies from that of a small pin- 
hole to a complete absence of the membrane. Both ex- 
tremes, however, are rare. Most frequently the diameter 
is fi'om three to ^yq lines. In regard to its pathological 
anatomy, we must generally discriminate whether the 
perforation is a rupture or a loss of substance. After a 
rupture the loss of substance is at first very slight, and 
it is only as the process advances that a breach, more 
or less extended, is formed by a gradual ulceration 
of the edges of the wound. The extent of the loss of sub- 
stance, however, is not in proportion to the duration of 
the otorrhoea, or to its intensity and character. I have 
observed cases in which the discharge from the ear has 
existed continuously for years without any loss of the 
substance of the membrane resulting, the edges of the 
fissure being in contact, and separating only on forcing air 
through the cavity of the tympanum. The most exten- 
sive perforations occur in otorrhoeas which come on after 
scarlatina ; though I have been surprised, in many cases 
of primary affection of the ear, where discharge or even 
temporary moistm^e in the meatus was denied, to see 
pretty extensive breaches in the membrane, involving 
more than one-third of it. 



76 Membrana Tympani. 

Althougli the membrana tympani may be entirely de- 
stroyed in the manner stated, yet, in extensive erosions, 
we very frequently observe a power of resistance in cer- 
tain parts. These are the peripheral portion of the 
membrane (V. Troltsch), which remains as a falciform 
remnant, and the part lying above the pocket of Troltsch, 
which, usually swollen and thickened, adheres to the 
upper end of the manubrium. 

Perforations of the membrana tympani present many 
variations of form and size on inspection. We can say 
in general that, in one class of cases, the post-mortem 
condition exactly corresponds with the appearance pre- 
sented during life, but differs more or less in others. 
In my opinion, this latter fact depends upon the swelling 
of the edges of the perforation, upon the amount of 
secretion lying in and about it, and, finally, also upon a 
change in the appearance of the opening from inclination 
of the membrane. 

It is easier to determine during life the actual form of 
the perforation in all those cases in which the secretion 
has become scanty. When secretion is present the 
form and size vary much, partly on account of the deposit 
on the edges of the rupture, and partly because of their 
varied amount of swelling ; so that, even at short inter- 
vals, we have a variety of appearances. 

If we examine a perforated membrana tympani, where 
the secretion is very abundant, we shall frequently 
enough, especially in children, be unable to distinguish 
either the individual parts of the membrane or the open- 
ing in it, the secretion being accumulated in large amount 



Appearances in F erf oration. 77 

before it, while a pulsating reflection often, tliongli not 
always, appears on tlie surface of the muco-purulent 
mass. Even after removal of tlie secretion, tlie a23pear- 
ance in many cases changes but little ; the membrane has 
a mottled, greenish hue, and the boundaiy-line between 
its periphery and the wall of the meatus is indistinct ; 
the manubrium and short process are not to be seen, and, 
at one or more points, there are reflections with or with- 
out pulsating movement. The point of perforation either 
cannot be distinguished at all from its surroundings, or 
is only visible when, by the Yalsalvian experiment or the 
air douche, the lips of the perforation are separated, and 
air and pus pass through the opening out of the tym- 
panum into the meatus in the form of bubbles. This 
often happens also in blowing the nose, with a sensation 
as of air whistling through the ear, and, in such cases, we 
frequently find on examination one or more bubbles 
near the membrana tympani, from which we may always 
infer the existence of a perforation. 

Besides these cases, in which, after removal of the 
secretion, the locality of the perforation cannot at once 
be made out on inspection, we find others, in which the 
situation of the aperture, most frequently in fi^ont of and 
below the manubrium, is indicated by a more or less mark- 
ed depression, ill defined, filled mth secretion, and often 
presenting a small reflection. This depression is puffed 
out on making the Yalsalvian experiment, if the Eusta- 
chian tube is per^T^ous ; and the lips of the opening being 
separated by the pressure of the air, the same appear- 
ance is presented as we have seen in the previous cases. 



78 Membrana Tympani. 

If the perfoi'ation is upon tlie anterior lower portion of 
tlie membrane, whicli is concealed by tlie anterior lower 
w^all of tlie osseous canal, we shall not be able to discover 
it by inspection, and can only infer its presence from tlie 
signs afforded by auscultation (see V. Troltsch, Anat. d. 
Ohres). 

Tlie a^^pearances are different where there is no con- 
tact of the lips of the lesion, but a gap from actual loss 
of substance. The appearances which here present them- 
selves vary greatly. If the gap is so small as not to 
measure more than a line in diameter, and the secretion 
with it is inconsiderable, w^e see, most frequently below 
or behind the manubrium, a dark opening, usually round 
(PL I. Fig. 9), which sometimes does not exceed 
the size of a pin-hole, and which might be easily mistaken 
at first sight for a small black particle lying upon the 
membrane. But if by the Valsalvian experiment we 
force air into the cavity of the tympanum, we usually 
perceive some secretion coming out of it, at first filling 
up the perforation and making it invisible. By continu- 
ing the pressure, air-bubbles pass through the opening, 
and remain for a short time accumulated before the mem- 
-brane. After their disappearance we again see the aper- 
ture, or it may be closed by secretion, or one of the air- 
bubbles may remain just in the perforation, and the light 
spot formed upon it may show a pulsating movement 
(Wilde, Y. Troltsch), though this is not always present. 
The perforations, which attain the size of a millet- or 
hempseed, present a similar condition, only that here, on 
inspection on different days, a variation in the size of 



Ap])earances hi Perforation. 79 

tlie opening will be observed, — an appearance wliicli 
might be easily mistaken for actual enlargement or dim- 
inution of the ga]^, did ^\e not remember that this fre- 
quently occurs from greater or less deposit of secretion 
upon its edges. We may mark, indeed, that by this 
occurrence the opening may completely disappear under 
our eyes. 

The perforations which have attained a diameter of three 
or four lines are more easily recognized. They are either 
circular or oval, or, less often, angular, and more 
frequently before and beneath the malleus handle than 
behind it, often changing their form rapidly, even 
with slight secretion, partly from increase and diminution 
of the swelling of their edges, and partly from deposit 
of secretion. The edges of the gap are either bright red, 
or pale, or dirty gray, and covered with creamy fluid. 
The appearance within the area of the opening varies 
accordino^ to the relation of the diseased membrana 
tympani to the promontory. If the mucous membrane 
of the inner wall of the cavity of the tympanum is not 
much softened, and, at the same time, the membrana 
tympani not strongly drawn inward, the edges of the per- 
foration standing free, we see behind the opening, 
either secretion in the cavity, or the dark grayish-red 
mucous surface of the promontory. If, on the contrary, 
the membrana tympani approaches the inner wall of the 
tympanic cavity so near that it comes in contact with its 
very much softened mucous covering, we see, less often, 
only a portion, but, generally, the entire circumference 
of the perforation attached to the promontory. In these 



80 Membrana Tympani. 

cases, also, the edges generally appear sharply defined, 
and the gray or brownish-red mucous membrane of the 
cavity, visible in the opening, may project even some- 
what beyond their level. In other cases, however, 
the boundary between the edges of the perforation 
and the mucous membrane of the promontory can- 
not be recognized, or can only be partially seen, 
since the remains of the membrana tympani and the 
promontory aj)pear to blend with each other, without 
any line of demarcation. But in this, as in the before- 
mentioned cases, changes may occur very rapidly in con- 
sequence of increase and diminution in the swelling of 
the parts, and different appearances be presented on 
different days. 

The membrana tympani presents in these, as well as 
in smaller erosions, a very variable appearance. In some 
cases it is covered with a layer of purulent secretion, and 
we see, in the midst of the greenish-yellow field, the dark 
or reddish gap. In others, the greenish -yellow coloring 
of the membrana tympani is dependent only partly 
on the secretion deposited upon it, and partly upon 
interstitial exudation. ISTot unfrequently, however, 
the membrane, through vascularization of the der- 
moid layer, exhibits a more or less intense redness, 
which either extends over its entire surface, or is 
only seen at certain sjDots, while the other portions, from 
secretion (PL I., Fig. 8), or interstitial exudation (PL II., 
Fig. 1), appear yellowish-green or dirty brown. In 
all these cases, where the middle ear and the mem- 
brane are secreting, we can but very seldon distinguish 



Appearances in Perforation, 81 

the manubrium, ^vliile tlie sliort process of tlie malleus is 
more frequently seen, like a small dirty yellow protube- 
rance, at tlie anterior U23per quadrant of the membrane. 

In perf oi'ations of the size specified, appearances change 
as soon as the secretion from the diseased parts ceases. 
We then see the aperture with dry, sharply defined edges, 
dark when small, but when it is three or four lines in 
diameter we distinguish the pale, grayish-yellow surface 
of the promontory. Not unfrequently the gap is entirely 
or partly filled with a greenish, dirty brown crust of 
still remaining secretion, which, sometimes shaped like a 
sausage, extends into the external meatus, and, on the 
other side, projects into the cavity of the tympanum. 
The short process is generally to be seen at the place 
designated, while the manubrium sometimes appears well 
marked or even prominent ; but at other times, in conse- 
quence of thickening of the layers of the membrane, is 
smTounded by interstitial exudation, and invisible, or is 
only indicated by a dark red (PL II., Fig. 4) or dirty 
brown bundle of vessels. The membrane, according to 
the density of the interstitial effusion, appears at some 
points, or more rarely throughout, of a pale yellow color 
or pearly gray, with glistening spots ; frequently with a 
sharply-defined, crescent-shaped calcareous deposit before 
the manubrium, and more rarely an irregular calcifica- 
tion upon the posterior portion of the membrane, or in 
the vicinity of the perforation (PL II., Fig. 4). The 
greater the loss of substance in the membrane, the more 
clearly does the inner wall of the tympanum come to 

view. If the anterior low^er half of the membrane is de- 

6 



82 Membrana Tympani. 

stroyed, the gap is bounded by the edge of the pos- 
terior remnant and the handle of the malleus, which 
sometimes lies against the promontory. The visible 
portion of the promontory is more or less reddened, 
or pale ; and we sometimes see the recess extending for- 
ward toward the osseous portion of the Eustachian tube. 
In children I have very often seen the anterior half of 
the membrane destroyed, the posterior portion appear- 
ing as a crescentic fold, with its sharply cut concave 
edge distinct from the dark red promontory, partly 
through diference of color, and partly by its shadow. 
When the low^er two-thirds of the membrane is destroyed, 
the perforation is generally kidney -shaped, from projec- 
tion of the malleus handle into the gap. In other cases 
the aperture is bounded by irregular edges. (See V. 
Troltsch, Krankheiten des Ohres.) 

The appearances are particularly interesting when the 
posterior half or the greater part of the membrane 
is destroyed; for then, besides the manubrium, we fre- 
quently obtain a view of portions of the incus and stapes, 
as well as of both fenestrse of the labyrinth. The 
appearances in this case also frequently vary according 
to the degree of swelling in the mucous membrane of the 
promontory, and the change of position which the audi- 
tory ossicles undergo through inflammatory softening, 
through retraction of the diseased mucous membrane, and 
of the tendons of the intrinsic muscles of the ear. 

If the posterior portion of the membrane is perforated, 
and the parts are still swollen and softened, we fre- 
quently see behind the anterior portion, which is thick- 



Appearance of the Ossicles am.d Promontory. 83 

ened and covered witli secretion, only the uniformly red- 
dened mucous membrane of tlie promontory, without any 
trace whatever of the auditory ossicles. On the other 
hand, if the swelling is slight, or has entirely disappeared, 
the anterior portion of the membrane appears either pearl 
gray, glistening, or even somewhat transparent, and some- 
times has a calcareous deposit in it. The border of the 
perforation is formed by the posterior edge of the clearly 
defined manubrium, and, below, by the sharply cut edge 
of the membrane, which, when it does not lie against the 
inner wall of the cavity, throws a noticeable shadow on 
the promontory. 

At other times this anterior portion may be seen as an 
irregular, much thickened, dirty yellow remnant (PL II., 
Fig. 3). The promontory appears as a pale yellow ele- 
vated surface, often with one large and several smaller red- 
dish-blue arborescent veinlets. At the most prominent 
parts, and indeed at those near the fenestra rotunda, a 
reflection from the moistened mucous membrane is gene- 
rally visible. We see in the posterior upper quadrant of 
the field — yet only where the membrane is destroyed to 
the extreme periphery — the articulation of the stapes and 
incus, and also the lower third of the long process of the 
incus, which is like a long yellow wand, one to two lines 
in length, standing out in relief. From its lower end the 
posterior shank of the stapes may be seen running back- 
ward and somewhat upward. The process of the incus 
and the posterior shank of the stapes, consequently, form 
an acute angle looking backward and upward — like that 
in the illustration of a transparent membrane (PL I., Fig. 



84 Membrana Tympani. 

4) — and if the long process of the incus is only moderately 
slender, it may be mistaken by the inexperienced for the 
anterior shank of the stapes. "^ 

In the majority of these cases, if the posterior portion 
of the membrane is wanting as far as the periphery, we 
may discover the niche of the fenestra rotunda below the 
visible portions of the incus and stapes, in the posterior 
lower quadrant of the field. It is to be seen as a 
roundish dark recess, from one to two lines in diame- 
ter, bounded by the posterior lower rim of the an- 
nulus tympanicus. Indeed, in most cases, on account 
of the oblique inclination of the fenestra rotunda to the 
axis of the meatus, we see only the shaded niche leading 
to the foramen. The membrane itself can only be seen 
in those rare exceptional cases in which, as Voltolini first 
observed, the fenestra is anomalously placed directly op- 
posite to the external meatus. Where the secretion still 
continues, the niche is entirely or partially filled with it, 
and a small punctif orm reflection then frequently appears 
upon its surface. If the secretion has entirely ceased, 
the recess appears more or less dark (PL II., Fig. 3). I 
have seen only one case in which there was a distinct re- 
flection at the bottom of the niche of the fenestra ro- 
tunda, of which, however, I cannot determine whether it 
was formed on the membrane of the fenestra, or on a 
false membrane in the niche. 

The appearance is dift'erent in those cases in which 
almost the whole membrana tympani is destroyed. 
Usually, as already stated, the portion lying near the 
short process of the malleus remains, as well as a part or 



Appearance of Promontory. 85 

tlie wliole of the firm tendinous peripheral ring. The 
former is seen either as a shapeless, thickened, grayish -red, 
or dirty white roll, at the anterior upper quadrant of the 
membrana tympani, or there are two crescentic or sickle- 
shaped folds (PL II., Fig. 2), which extend down to 
either side of the short process of the malleus, and shade 
the upper portion of the red or pale yellow promontory. 
If the extreme periphery of the membrane remains, it 
is most distinct anteriorly, and also appears as a sharply- 
defined, sickle-shaped, prominent band ^ — especially in 
those cases in which little secretion adheres to the deep 
parts. 

The appearances further change according to the con- 
dition of the mucous membrane of the promontory, its 
degree of swelling and hypersemia, and the position of the 
auditory ossicles. The promontory appears (after the 
secretion is thoroughly removed fi'om the ear) either uni- 
formly deep red, with glistening spots here and there ; 
or the ramifications of the vessels are clearly distinguish- 
able, and the promontory more yellowish-red, as seen 
in PL II., Fig. 2 and 3. 

Sometimes, however, and particularly in cases where 
the suppm^ative process in the middle ear has long 
since ceased, we find the promontory of normal aspect, 
vdthout swelling or hyperaemia, and not at all dif- 
fering in appearance from a preparation of the normal 
ear taken from the dead subject. 

In the course of otorrhoea of long standing, vegetations 

* See the excellent descriptions of these conditions of the membrana tym- 
pani by Y. Troltsch, in his Krankheiten des Obres. 1863. 



86 Memhrana Tympani. 

not unf requently occui' on the softened mucous membrane 
of tlie promontory. It then appears uneven, glandulous, 
uniformly dark red, or covered here and there with gray- 
ish exudation, and, even when the membrane is com- 
pletely destroyed, there is nothing to be seen of the 
fenestra rotunda or ovalis. Only in one case could I see 
the head of the stapes mth its slight depression in the 
midst of the swollen membrane. The manubrium, wdth 
the short process, sometimes projects out fi^ee into the field 
of view, as a yellowish-gray, usually short rod ; and its 
outline, sharply defined from the deeper-lying background, 
upon which it sometimes casts a visible shadow, enables 
us, at the first glance, to recognize the promontory as 
such, and renders it impossible to mistake it for an in- 
flamed membrana tympani. If, however, the hypertro- 
phy of the mucous membrane is so considerable that it 
extends out beyond the level of the annulus tympanicus, 
the malleus is either enveloped in it, or destroyed by 
caries, or extruded ; and we certainly cannot then easily 
determine, even when the reddened surface presents a 
change of curvature on forcing air into the cavity of the 
tympanum, whether it is the membrana tympani or the 
promontory that lies before us. It is sometimes impossi- 
ble to make a diagnosis in these cases, even with the 
most careful examination, and our first information of the 
true state of things is derived from the course of the dis- 
ease. There was a case illustrating this, which I watched 
for a long time at the clinic of Prof. Oppolzer. It was 
that of a girl who for several years had had a discharge 
from both ears. After carefully cleansing the right ear of 



Differential Diagnosis, 87 

secretion, inspection showed a uniformly reddened, uneven 
surface at tlie bottom of the meatus. On forcible pres- 
sui-e, the air whistled out through the middle ear into the 
meatus without any change whatever being perceptible 
in the appearance. The hearing distance was considera- 
bly diminished. On careful touching with a sound bent 
at right angles, we found softened spongy tissue upon a 
moderately resistant base, and from all the appearances 
concluded that the membrana tympani w^as completely 
destroyed, and that we were looking at the mucous 
membrane of the promontory, considerably softened, 
and rising above the annulus tympanicus By the 
daily employment of the air douche, and by cauteri- 
zation every third day with a little drop of caustic melted 
upon a wire bent at right angles, we expected a decrease 
in the swelling of the mucous membrane, and a freer 
movement of the imbedded stapes. After about fourteen 
days, however, the short process of the malleus became 
quite distinctly visible anteriorly and above, and, after a 
few days more, we could recognize, in the no longer se- 
creting surface, the very opaque membrana tympani, 
with a perforation at its anterior low^er part some lines 
in diameter, and the manubrium marked by a bro^vnish- 
red injection. The hearing distance for speech amounted 
to more than twelve feet. 

Just as we have seen that an inflamed and softened 
membrana tympani may sometimes bie mistaken for the 
promontory, so it is possible, on the other hand, also to 
mistake the swollen mucous membrane of the promontory 
for the membrana tympani. This occurs especially in 



88 Memlrana Tym.pani. 

cases wliere there is a pulsating reflection on the uneven 
surface of the field of view, which changes place and form 
when air is forced into the middle ear. We are con- 
vinced that these appearances are |)i"esented, not only 
when an inflamed membrana tym]3ani swells out upon 
the entrance of air into the cavity of the tympanum, but 
may also occur on the swollen mucous membrane of the 
promontory. For instance, if air is forced into the tym- 
panum by the Valsalvian experiment, a venous conges- 
tion of the cerebral parts always takes place during the 
manipulation. Now, since this congestion also affects 
the mucous membrane of the promontory, it becomes 
more swollen, even when no air enters the cavity, and the 
reflection upon it consequently shows a change of place 
analogous to that which occurs in the arching out of an 
inflamed membrana tympani. 

That the position of the auditory ossicles must be a vary- 
ing one where there is great loss of substance in the mem- 
brana tympani, is evident from the fact that their points 
of support and attachment become variously altered by 
the morbid process. The handle of the malleus seldom 
remains in the normal position when loosed from its at- 
tachment to the membrana tympani. Since the tendon 
of the tensor tym])ani ^vould draw the manubrium in- 
ward, acting in antagonism to the elastic elements of 
the membrane, when the membrane is destroyed it 
will na^;urally, in consequence of the withdrawal of 
the antagonizing force, obtain the mastery, and pull 
the manubrium inward more or less strongly. In con- 
sequence, its lower end is usually strongly inclined to- 



Heiraetioii of the Mamtbrium. 89 

ward the inner wall of tlie tympanum with pers^^ective 
foreshortening, so that it often apj)ears like a little 
button belo^7 and behind the short process (PL II., 
Fig. 2). Hence it not unfrequently happens that 
the lower end of the manubrium is brought into con- 
tact with the inner wall of the ca^^ity of the tympanum, 
and, mth continued contact, adheres to the mucous mem- 
brane of the ]3romontoiy. It appears then usually some- 
what thickened at the point of contact, and, not unfre- 
quently, one or more little vessels extend from this point 
downward on the promontory (PL II., Fig. 2). The 
breaking up of this anomalous adhesion is, in many cases, 
not without difficulty. AAHien the lower end of the ma- 
nubiium is within half a line of the promontory, we can 
scarcely say — even where the meatus is uncontracted — 
whether it is in contact or not. This will be at once ex- 
plained when we consider that the direction of our axis 
of vision, in inspecting the deep parts of the meatus, can 
scarcely be changed to any considerable extent, and that, 
consequently, our judgment concerning the degree of sep- 
aration of parts lying behind one another, especially 
where the distance is small, is entii-ely unreliable. 

In some cases, however, the diagnosis is by no means 
difficult, when, as we once observed it, the end of the 
manubrium is connected with the promontory by a little 
band more or less strongly developed, appearing like 
a projecting fold. On the other hand, the recognition of 
the condition is impossible where the central part of the 
membrana tympani is destroyed, and the loosely attached 
manubrium is so drawn inward and backward that its 



90 Membrana Tympani. 

lower half is concealed by the posterior portion of the 
membrane still remaining (PL II., Fig. 1). 

In contradistinction to this apparent shortening, we 
meet, in many cases, with a real shortening of the manu- 
brium through atrophy, the result of long-continued sup- 
puration in the ear. In such cases we find it not only 
shorter, but, especially at its lower end, reduced in size, 
uneven, and pointed like a rusty tack. 

Yet, even in complete destruction of the membrane, 
we shall sometimes be unable to discover anything of the 
manubrium. It may be wanting, in consequence of the ex- 
trusion of the entire malleus, or be destroyed by caries as 
far as the neck, or di'awn by retraction of the tensor tym- 
pani, or by anomalous bands of connective tissue, so far 
backward and into the upper recess of the cavity of the 
tympanum, that it is concealed by the upper and poste- 
rior wall of the osseous meatus. 

Similar changes are also observed in the long 23rocess 
of the incus, which, in like manner, atrophies, or, after 
separation from the head of the stapes, is drawn inward 
and upward by anomalous adhesions, and consequently 
disappears from view. The condition of the membrane is 
especially noteworthy in luxation of the articulation of 
the stapes and incus. I have observed this lesion in 
two cases. In one, a part of the anterior portion of 
the membrane was still adherent to the distinctly re- 
cognizable manubrium. In the other, the membrane was 
reduced to a small remnant on either side the short 
process, the manubrium being quite free ; and close be- 
hind this we distinctly saw the long process of the in- 



- 1. 



Taf. H. 












10 



12. 






|em.v. D' Polilzer ; chromolith.v.D': C.Heitzr 



Lith.Anst.v.F. Koke.Wie 



Ruptures, 91 

cus, completely loosened however from its connection 
witli the stapes, which, also free, was visible mth the 
articular depression on its head and its two crura. The 
hearing distance for speech in one case still amounted 
to six feet or more. 

A view of the stapes, as has been said, is only possible 
when the posterior portion of the membrane has been 
destroyed to the periphery, and we can hardly ever see 
the entire chain of auditory ossicles. In its natural con- 
nection with the incus, only the posterior shank of the 
stapes is to be seen ; while, in detachment or destruction 
of the long process of the incus, the head and both crura 
are visible, though the base is only partially so, because 
the posterior haK of the fenestra ovalis is concealed by 
the posterior portion of the annulus tympanicus. For 
this reason, also, when the crura of the stapes are both 
destroyed by caries, we only obtain a view of the anterior 
part of the fenestra ovalis closed by the base of the 
stapes. 

With ^perforations of the membrane we class the 
ruptures arising from direct mechanical violence, or from 
concussion. The form of the aperture varies with the 
shape of the instrument inflicting the wound, and the 
nature of the force. Accordingly we find it roundish 
(as, for instance, when a hair-pin has been thrust in), or 
quite irregular, with ragged edges suffused with blood, 
if the wound has been made by a blunt instrument 
(for instance, by pressing in a foreign body that has 
entered the meatus). The ruptures occurring among 
artillerists, fi'om sharp concussions of air, are described 



92 Memhrana Tympani. 

as rectilinear slits lying behind the manubrium and par- 
allel with it, which, after healing, leave a linear grayish- 
white scar. 

The impairment of function occurring in consequence 
of perforation of the membrane, as older observations 
have already shown, is not proportioned to the extent of 
the loss of substance. With small perforations we find 
not unfrequently a high degree of deafness ; while 
sometimes, on the other hand, in case of perforations 
involving more than two-thirds of the membrane, the 
hearing distance, if not normal, may still be pretty good. 
In the impairment of function, there are generally sev- 
eral factors to be taken into account. Apart from the 
fact that, in consequence of the loss of substance, the 
vibrating surface is diminished, and irregular vibrations 
of the membrane occur, there also come in, as essential 
factors in the impairment of function, the thickening of 
the membrana tympani, the diminished mobility of 
the auditory ossicles by the accumulation of secretion, 
and by being enveloped in the swollen and hypertrophied 
mucous membrane, and by the formation of adhesions, 
and, finally, the altered relations of pressure upon the 
labyrinth arising from the pathological changes at the 
fenestra ovalis and rotunda. It is the changes at the 
fenestrse, especially, that regulate the degree of impair- 
ment of function. If the mobility of the stapes in 
the fenestra ovalis is not materially interfered with, and 
the covering of the fenestra rotunda not much thick- 
ened, the waves of sound, passing by the membrana tym- 
pani, the malleus, and incus, will strike directly upon the 



Healing of F erf orations, 93 

base of tlie stapes tlirougli the perforation, and so still 
reacli tlie labyrinth in considerable number. In this 
way only can the slight degree of impairment of function 
in case of extensive loss of substance be explained. 



Healing of Perforations. 

The fact that gaps in the membrana tympani arising 
from loss of substance can close again, has been re- 
marked by several authors in the older literature of 
aural surgery. Yet these cases are regarded as so in- 
frequent that, even to the present day, physicians as 
well as the laity connect with the diagnosis of perfora- 
tion of the membrane a decidedly unfavorable prog- 
nosis as regards its curability. The more recent patho- 
logico-anatomical researches of Toynbee, Yon Troltsch, 
and others have, nevertheless, shown that cicatriza- 
tion pretty frequently occurs, even with extensive 
loss of substance. And Yon Troltsch especially, 
after many observations, has demonstrated (loc. cit.) 
a considerable degree of recuperative power of the 
membrane, which he connects with its great vascu- 
larity. 

The conditions for the healing of perforations depend 
]3rincipally upon the state of the mucous membrane of 
the tympanic cavity. So long as the purulent secretion 
in the middle ear continues, if only in a moderate de- 
gree, permanent cicatrization of the perforation is 
impossible. I have repeatedly, in the course of 
purulent catarrh of the middle ear, seen distinctly 



94 Memhrana Tym/pani, 

recognizable perforations — tlirougli wMcli, on forcing air 
into tlie tympanum, bubbles came out into the meatus — 
rapidly close, so tliat, on the following day, tlie greenish- 
yellow, swollen, and secreting membrane was bulged 
out by the pressure of air, without any passing through 
at the points before observed. Such unions last but a 
short time, often only a few hours, and are then over- 
come by the pressure of the pus meanwhile accumulated 
in the cavity — a strong sensation of tickling in the 
depths of the ear often preceding. I have, however, 
seen these temporary closures in the course of otorrhoea 
only in cases where the edges of the perforation were in 
contact, having never been able to observe them dur- 
ing the continuance of the discharge ; the perforations 
were somewhat larger, amounting to more than two or 
three lines in diameter. Yet I am of opinion that 
sometimes simply a closer superposition of the edges of 
the rupture without actual union, may suffice to present 
such resistance, when air is pressed into the tympanum, 
that the membrane arches outward mthout any separa- 
tion of the edges occurring. 

Manifold are the variations presented in the process 
of healing in case of perforations — ^not only with respect 
to the alteration of the form and position of the mem- 
brane, but also to the consequent impairment of function. 
These varieties should be successively examined in 
detail, and, keeping the practical aim of this work in 
view, we will illustrate the descriptions of the various 
forms by the records of cases. 

In one series of cases the perforations heal with coin- 



Healing of Perforations, 95 

jplete recovery of tlie liearing ^oioer^ and ivitJiout leaving 
heJhind any pathological changes in the membrane. I 
have more frequently observed this result after tlie sub- 
sidence of acute purulent catarrh of the middle ear, but, 
in some cases also, after the cessation of chronic otor- 
rhoea. The process of healing sometimes goes on very 
rapidly. In short, we are completely surprised to find 
an unbroken glistening surf ace, where a few days before 
a swollen, mottled, or reddish-yellow membrane, could 
be seen, on which no traces of the malleus were dis- 
coverable. In some cases, however, we have an oppor- 
tunity of watching the progress of the healing process, 
where we observe, first, a noticeable decrease of the 
secretion, soon after a diminution and, finally, a closure 
of the perforation; the membrane, as well as the adjoin- 
ing parts of the osseous meatus, becomes covered with a 
moist, dirty brown, often tenaciously adherent layer of 
secretion and epidermis, which soon dries, and when this 
is worn off or removed by artificial means, the normal 
membrana tympani comes to view. 

Case : Acute Catarrh of the Middle Ear on both sides with high 
degree of Deafness. — On the right side : Croupous Hemorrhagic 
Exudation into the Tympayiic Cavity^ with Perforation of the 
posterior part of the Memhrana Tympani. — On the left : Accumida- 
tion of JPus in the cavity, with bulging of the Membrane. — 
Paracentesis of the Membrane. — Complete Recovery. 

Miss D., aet. 15, native of Bavaria, blonde, well-developed, and of 
vigorous appearance, was, while in Vienna, on the 13th of January, 
1862, attacked by so violent a fever that, during the first few days, 
the outbreak of an exanthema, or the appearance of an exudative 
process, was expected. On the evening of the third day, the patient 



96 Memhrana Tymjpani, 

first complained of sharp pain and stinging in the ears, soon fol- 
lowed by a slight degree of deafness, which, on the following day, 
after the fever had suddenly abated, became very great. On the fifth 
day some blood was noticed in the right meatus, and the hearing 
power was almost entirely lost. 

Upon the sixth day of the illness I saw the patient for the first 
time. She was out of bed, but looked pale and exliausted, and was 
compelled by fatigue to sit down after a few steps. She complained 
of tinnitus aurium and stinging in the left ear, but her head was free 
from pain and vertigo. 

Examination revealed the following condition : On the right side, 
some coagulated blood in the meatus, after the removal of which 
with the syringe, a perforation is seen upon the posterior upper por- 
tion of the membrane, occupying nearly a third of its whole ex- 
tent. A croupous, fibrinous exudation projects from the cavity of the 
tympanum through the opening into the meatus, in the form of 
a brownish-red irregular mass. The anterior lower half of the mem- 
brane is still strongly arched outward, with apparently little change 
of structure and the cone of light well marked. The manubrium is 
invisible. Upon the left side, there is intense injection of the osseous 
portion of the meatus, the redness extending to the membrana tym- 
pani, which, with the exception of the anterior upper quadrant, ap- 
pears livid, lustreless, and soaked with serum. At the anterior upper 
portion mentioned the membrane is seen projecting in the midst of 
the red field, in the form of a sac of the size of a lentil, hanging 
down and having a purulent green color. 

The hearing distance on both sides is greatly diminished; my 
watch (the average normal distance being twelve feet) is not heard 
on either side, even when firmly pressed against the external ear. 
The perception of the sound of the watch through the cranial bones 
is likewise completely lost, and the power of understanding speech 
is entirely w^anting on the right side, while on the left only very 
loudly spoken words can be heard at the distance of two feet. 

We proceeded to the examination of the Eustachian tube. As 
the patient was weak and exhausted by the preceding fever, the 



Politzer'^s Air -Douche, 97 

introduction of the Eustachian catheter did not seem advisable ; 
wherefore I employed the new method devised by me for opening 
the Eustachian tube, a short description of which we will here 
repeat for the benefit of those readers to whom it may not yet be 
known. The patient, being seated, takes some water into his mouth, 
to be swallowed at a given signal. The surgeon, placing himself 
most conveniently at the right of the patient, grasps with his 
right hand an india-rubber bag about as large as the two fists, and 
introduces the nozzle of a somewhat curved hard-rubber tube, 
movably connected with it, about half an inch into the nostril, so 
that its concavity is in contact with the floor of the naris. The sig- 
nal to swallow is now given, both alae are at the same time closed 
air-tight over the instrument witli the thumb and forefinger of the 
left hand, and, by a forcible pressure of the right hand, the air is 
driven out of the bag into the now shut nasal cavity. 

After we had in this manner compressed the air in the cavity, 
the patient stated that she had felt nothing in the right ear, while 
on the left she had distinctly perceived the entrance of the air into 
the tympanic cavity. The trial of the hearing distance, now repeated, 
showed no change on the right side ; but on the left the distance 
amounted to two inches for the watch, and to three feet for the 
voice, and, what was remarkable, she now heard the watch through 
the cranial bones quite distinctly. 

From the result of the examination, we inferred the following 
changes in the ear : Acute inflammation of the mucous membrane of 
the middle ear, and, as a consequence, on the right side a croup- 
ous hemorrhagic exudation, which was formed in such quantity that it 
had forced through the posterior portion of the membrana tympani, 
strongly arched the remainder, and, by completely enveloping the 
auditory ossicles, wholly stopped their vibrations, and hence the 
entire deafness. On the left, we might infer from the greenish 
circumscribed protrusion of the membrane, a copious formation of 
pus. The loss of the perception of sound through the cranial bones 
might either have been the result of excessive pressure from the 
cavity of the tympanum upon the feuestr^e rotunda and oralis, and 

7 



98 Membrana Tym/pani. 

consequently, also, upon the contents of the labyrinth ; or, simulta- 
neously with the acute inflammation in the middle ear, a serous 
soaking of the membranous labyrinth might have occurred, and the 
susceptibility of the auditory nerve been iu this way impaired. 

We could corroborate the first inference respecting the left ear 
after the employment of the air-douche, since, as soon as a 
pait of the pus was forced out of the cavity by the current of air, 
and the pressure in the tympanum thereby diminished, the percep- 
tion of sound through the cranial bones returned again. On the 
other hand, the air-douche, as has been stated, was without effect 
upon the right ear, because the resistance opposed by the stiff exuda- 
tion in the cavity was too great to be overcome by it. 

The treatment employed had for its object the softening and speedy 
removal of the stiff exudation in the right ear. For this purpose, 
warm water was directed to be dropped into the right meatus every 
two hours ; and since, iu the left ear, rupture of the membrana tym- 
pani by the accumulated secretion was imminent, and the pent up 
purulent matter might, in the mean time, exercise an injurious influ- 
enee on the neighboring parts of the organ, we decided on performing 
paracentesis of the membrane at once after the first examination of 
the patient. For this purpose, having the auricle drawn backward 
and upward, so as to straighten the meatus, I illuminated the mem- 
brane by a reflector held in the left hand, then carried a sharp cata- 
ract needle toward the prominence designated, and, entering it at 
the most prominent point, enlarged the wound somewhat downward 
in withdrawing the instrument. Several drops of pus immediately 
came out of the opening into the meatus. 

On the following (7th) day we found already on the left side a 
copious discharge through the artificial opening, while in the right 
ear the condition w^as unchanged. After the employment of the air- 
douche, the hearing distance on the left side again improved — to four 
inches for the watch, to five feet for the voice ; hearing distance on 
the right side w^as unchanged, the air not entering the tympanum. 
The instillation of warm water was continued. 

The right ear showed an essential change on the day after. The 



Case^ continued, 99 

stiff mass of exudation was broken up, and the meatus was filled 
with a brownish-colored pus, after the removal of which we observed 
a pulsating movement of the secreti'jn in the perforation. After tlie 
air-douche, an essential improvement in the hearing on this side was 
at once apparent, the watch being heard at two inches and the voice 
at four feet ; and on examining the meatus again, we saw at the bot- 
tom of it a large number of air-bubbles. The resistance which the 
exudation had opposed to the air-douche on the previous days was 
consequently overcome by its softening into pus, and the air could 
now easily enter the cavity of the tympanum. The perception of 
sound through the cranial bones was still entirely wanting. 

On the ninth day the discharge was equally abundant on both 
sides. After syringing out the right ear, we discovered a perforation, 
four or five lines in diameter, and with intensely injected edges, 
through which, on trial of the "new method," the air passed in bub- 
bles. In the left ear, the edges of the perforation, which were in 
fiont of the manubrium, w^ere in contact, and separated from each 
other as soon as the air was forced through the middle ear. The 
hearing distance, compared with yesterday's, was somewhat less, but, 
after the air-douche, rose to two feet for the watch and twelve feet 
for the voice, on both sides. There was also perception of sound 
through the cranial bones on both sides. General condition very^ 
good. Ordered: To syringe out the ears with lukewarm water 
several times a day, and, since the signs of irritation had entirely 
disappeared, to fill the meatus after each syringing with a solution of 
sulphate of zinc, two grains to the ounce, and allow it to remain ten 
minutes in the ear. 

During the next three days the air-douche by the new method 
was daily employed, and we observed a constant improvement. The 
secretion rapidly grew less. The perforation on the right side dimin- 
ished, and the hearing distance rose to four feet for the watch and 
to thirty-six for the voice. - 

From that time the improvement was rapid, so that on the four- 
teenth day the secretion had ceased, and both perforations had cica- 
trized simultaneously. After removal of the dried secretion remain- 



100 Membrana Tymjpani, 

ing in the meatus, we saw, for some days still, a slight hyperaemia 
on the manubrium, and after this had passed away the membrana 
tympani appeared entirely normal^ as well in respect to lustre as in 
cm'vature and color, and the hearing distance, both for watch and 
voice, was likewise fully normal. The young lady, whom I have 
since seen repeatedly, has not, from the time of that attack till 
now, — that is, for two years and a balf, — expeiienced the slightest 
trouble in the ears. 



When, as sometimes happens after an obstinate dis- 
charge from the middle ear has been checked, the per- 
foration cicatrizes without leaving behind any change in 
the membrana tympani, yet a certain degree of deafness 
remains, this depends either upon a deposit of patho- 
logical products around the auditory ossicles, whose 
vibration is thereby interfered with, or there is still 
present some degree of swelling of the mucous mem- 
brane of the tympanic cavity, and of the lining of the 
Eustachian tube, — this latter usually occurring at the 
same time. The diflS.culty of hearing is then conse- 
quent upon the temporary closure of the tube, the air in 
the cavity of the tympanum becoming absorbed, and the 
membrana tympani, together with the auditory ossicles, 
being so strongly forced inward by the pressure of the 
external air as to lose a part of the vibratory power. 

Recovery from all these conditions is possible. So 
long as the morbid products are not organized they can 
be broken up and removed by frequent air-douches by 
means of the catheter or of the new method, and, fur- 
ther, by saline injections into the cavity of the tym- 
panum through the Eustachian tube. Swellings of the 



Note : Chronic Catarrli of Middle Ear, 101 

lining membrane of tlie tube and of tlie tympanum are 
also curable by means of the air-douche and injections of 
astringent solutions. Where, on the contrary, organized 
exudations affect the mobility of the auditory ossicles, 
or the elasticity of the fenestrse of the labyrinth, we can- 
not expect a restoration of the normal hearing distance."^* 

* I take the liberty of giving, in the following note, a brief abstract of the 
treatment of chronic catarrh of the middle ear and Eustachian tube without 
perforation of the membrana tympani. After first inspecting the meatus and 
membrane, we determine the hearing distance, both for the watch and the 
voice, and then proceed to the examination of the Eustachian tube — forcing 
air through it into the cavity of the tympanum in the way before specified 
("new method"), or by the catheter, by means of an otoscope determining 
whether a current of air enters the cavity. When the hearing distance is 
hereupon noticeably increased, — an inch or a foot for the watch, and several 
feet or fathoms for the voice, — and we may infer therefrom the existence of 
swelling of and secretion from the mucous membrane of the tympanum and 
Eustachian tube, besides the employment of the " new method," injection of 
a solution of zinc into the middle ear is indicated. We use for this purpose 
a solution of from four to eight grains to the ounce of water. The catheter 
(the best for this purpose are those made of hard rubber, after our design, by 
Leiter of Yienna) is introduced into the Eustachian tube, and fixed with the 
left hand. Some of the astringent solution is dropped into it by means of a 
little glass tube, and blown into the cavity of the tympanum by compressing 
with the right hand a rubber bag attached to the catheter. These injections 
should generally be repeated every three days, and continued for from three 
to five weeks. If, as in many chronic cases, no complete recovery, but only a 
more or less marked improvement, takes place, the injections, after some 
months, should be renewed for two or three weeks, in order, if possible, to 
prevent the further increase of deafness. 

If, on the contrary, after repeated trial of the air-douche, there is little or 
no increase in the hearing distance, so that we may infer that the deafness 
is caused by the sequelas of the catarrhal affection — viz., thickening of the 
mucous membrane, and of the' covering of the auditory ossicles, with rigid- 
ity and diminished mobility — we can expect improvement only from the use 
of moderately stimulating injections, together with the air-douche. The follow- 



102 Memhrana Tym^yani, 

The cases in whicli, after closure of the ]3erf oration, 
distinctly visible cicat/i^ices remain in the membrana tym- 
23ani are more frequent than those just described. For 
even perforations of long standing are closed by the 
outgrowth of connective tissue from their edges, often 
in a surprisingly short time. The cicatrix thus formed 
consists of a thin stratum of connective tissue, covered 
on either side by a delicate epithelial- layer. Elastic 
fibres, such as constitute the substantia propria, are 
entirely wanting in it. 

The size of these cicatrices varies from that of a pin- 
head to two-thirds of the area of the membrane, but 
those which most frequently come under observation lie 

ing solutions seem best fitted for injectiori : 5 Ammonioe muriat. gr. xx., 
Aq. dest. |j. ; or, ]J Potass, iodid. gr. x., Aq. dest. |j. ; or, 1^ Sodii 
chJoridi gr. v., Aq. dest |j. After the employment of these injections 
frjm tTVO to four times a week, in the same manner and with the same 
intervals as those before mentioned, we shall in some cases obtain essential 
improvement in the hearing, in others only slight, and in others still, shall 
overcome the faint ringing and vertigo — symptoms which accompany the 
chronic thickening of the mucous membrane of the middle ear. 

The improvement obtained by the use of these saline injections, in the 
cases supposed, seldom continues, since the thickened tissue of the mucous 
membrane, which was somewhat softened by the air-douche and the stimu- 
lating injections, has, like cicatricial tissue, a tendency to retract, whereby 
the rigidity of the auditory ossicles returns. We must, therefore, repeat 
the injections and air-douche from time to time — for instance, every three, 
four, or six months — every other day during from two to four weeks. The 
introduction of elastic bougies into the Eustachian tube, when it is con- 
tracted, is sometimes attended with essential improvement. 

We must mark the fact, as of especial importance, that a constant or too 
long employment of the injections, or of the air-douche, is injurious, while a 
treatment interrupted by intervals of weeks or months proves most effectual. 



Cicat/rices, 103 

between these extremes, having a diameter of from three 
to ^YQ lines. 

Their sJiajpe is, as a rule, roundish or elliptical, some- 
times triangular ; but large cicatrices, occupying the 
inferior and lateral parts, from the projection of the 
manubrium down into them, appear kidney-shaped. Like 
the perforations, they present themselves at the parts 
lying intermediate between the annulus cartilagineus 
(peripheral portion of the membrana tympani) and the 
manubrium. The thin cicatrix very rarely extends to 
the extreme periphery, more frequently, however, to the 
edges of the manubrium. 

On inspection of the membrana tympani the cicatrices 
appear as sharply defined, usually depressed, transparent 
spots, which, because the surrounding parts are commonly 
of a dull grayish white, also present a darker appearance. 
Their depression below the other parts of the membrane 
is in consequence of the lack of elastic elements, whereby 
their power of resistance to the pressure of the external 
air becomes considerably diminished. This external 
pressure preponderates even in the normal condition, if 
tubal obstruction has existed only for a little time. 
Very fi'equently, at the bottom of such depressions, one 
or more punctiform, or larger irregular reflections, are to 
be seen. 

The border of the cicatrix is, in perhaps the ma- 
joiity of cases, sharply defined all around (Plate 11. , Fig. 
6, before and under the manubrium), so that the edges 
often appear with a double contour and glistening. 
Sometimes, however, the border is distinct only on one 



104 Membrana Tympani. 

side, while on the other sides it sinks imperceptibly 
into the surrounding parts (Plate II., Fig. 10, behind 
the manubrium). Indeed, there are cases where the 
cicatrix appears like a shallow depression without any 
distinct border, which, in the Valsalvian experiment, is 
Y^vj easily swelled out, thus forming folds and glistening 
spots. The color of these depressions differs according 
to the degree of their transparency. Rarely they are 
of a dull pearl gray, and their color is then little modi- 
fied by the parts lying behind. On the other hand, the 
cases are more frequent, — the more so the nearer the 
cicatrix approaches the inner wall of the tympanum, — in 
which the color of the deeper parts can be seen through 
them, and an inference respecting the condition of those 
parts consequently be drawn. We shall, therefore, see 
the promontory of a dark violet red, where there is 
still existing hypersemia of the mucous membrane of the 
tympanum, and of a pale yellow when in the normal 
condition. Sometimes I have seen one or more well- 
developed vessels of new formation extending even upon 
the cicatrix. 

Just as, in case of perforations behind the manubrium, 
under the conditions before stated, we distinctly saw 
parts of the incus and stapes, as well as both fenes- 
trse of the labyrinth, so we find also that these parts 
are to be seen through extensive cicatricial formations 
at these points. Most frequently the lower end of 
the long process of the incus, and its articulation with 
the head of the stapes are visible. In one case we could 
quite distinctly make out the head of the stapes turned 



Depressed Cicatrices. 105 

outward and downward with the tendon of tlie stape- 
dius muscle. Less frequently have I been able to see, 
through the cicatrix, the niche of the fenestra rotunda. 

These structures are naturally the more distinct the 
nearer the cicatrix approaches the inner wall of the 
tympanum, so that sometimes indeed, in cases where 
they are in contact, the process of the incus and the 
head of the stapes, at first sight, seem to be adherent 
to the cicatrix, since they form projecting prominences 
on its surface. These, however, disappear when, by 
forcing air into the tym23anum, the cicatrix is pressed 
outward, and thus its contact with the deeper parts of 
the middle ear for a short time prevented. 

Where there is close contact between the cicatrix 
and the promontory, the latter also stands out as a 
marked prominence, reddish or yellomsh in color, and 
usually glistening, and upon it we sometimes discover, 
through the cicatricial tissue, one or more well-devel- 
oped vessels. In one case, I could distinguish through 
the cicatrix irregular, friable, white or yellowish- 
white masses, — standing out from the lower or poste- 
rior wall of the tympanum into its cavity, — which were 
interpreted as the calcareous residua of old morbid 
processes. 

If in a given case we have to distinguish a depression 
from an actual adhesion of the cicatrix to the inner 
wall of the tympanum, we must accurately observe the 
changes which the membrane undergoes whenever air 
is in any way forced into the middle ear. Depressed 
cicatrices always undergo, thereupon, a marked change 



106 Membrana Tym/pani. 

of curvature, swelling out to tlie level of the rest of the 
membrane or beyond it. The reflections disappear or 
become faint. The cicatrix itself often forms irresrular 
folds and loses its transparency, especially when the 
air is pretty strongly forced in, becoming suddenly of a 
dull gray. If the cicatrix were larger, and approached 
the inner wall of the tympanum even to contact, and 
we could previously see the promontory with isolated 
vessels, and portions of the long process of the incus 
and the stapes, the appearance completely changes upon 
forcing air into the cavity, for the cicatrix is then 
arched out, and there is nothing to be seen of the 
structures within. After a time, however, the air 
which was forced in is absorbed, and the former ap- 
pearance is again presented. 

The parts of the membrana tympani surrounding the 
cicatrices are seldom of normal transparency, but com- 
monly are more or less uniformly dull gray, and thick- 
ened. I have pretty frequently found, with a large 
kidney-shaped cicatrix extending from the manubrium 
downward and laterally, little calcareous deposits, from 
one and a half to two lines in diameter, before and be- 
hind the upper end of the handle. The manubrium 
itself undergoes noteworthy change of position only in 
those cases where it, in great part, projects into the 
cicatricial area, and its lower end is drawn toward the 
promontory. 

We must remark, as especially worthy of notice, that 
changes in the membrane, similar to those we have de- 
scribed as cicatricial, are observed also in cases where 



cicatrices — Functional Disturbance. 107 

no perforation lias previously occurred, particularly in 
the course of chronic catarrh of the middle ear without 
ruptui^e of the membrane; for, in this disease, circum- 
scribed affections of the mucous layer of the membrana 
tympani not unfrequently occur, in consequence of 
which the layers of the substantia propria correspond- 
ing to the afected spots become atrophied. From the 
immediate contact of the mucous and dermoid layers 
a thinned area is now presented in the membrane, not 
differing at all in appearance from cicatricial formations. 
We have observed the development of such circum- 
scribed atrophies in several cases. We can speak 
with certainty of cicatrices only when they have been 
formed under our o^vn eyes after perforation. We can 
only conjecturally regard them as such, when the 
patient states that there has been a previous discharge 
from the ear ; while in cases in which there is no recol- 
lection of an otorrhoea, the diagnosis between cicatrices 
and circumscribed atrophies is impossible. 

What we have said of perforations, relatively to im- 
pairment of function, holds good also of the cicatricial 
formations just described, which are not adherent to the 
inner wall of the tympanum. Accordingly we find, not 
unfrequently, with extensive cicatrices formed after the 
subsidence of otorrhoeas, and often invohdng two-thirds 
of the membrane, pretty good hearing if the morbid 
process in the middle ear has terminated without 
impairing the movements of the articulations of the 
auditory ossicles, or at the fenestrse. Inversely, a high 
degree of deafness occurs with small cicatrices, if the 



108 Memhrana Tympani, 

mobility of the ossicles or at the fenestrse is im- 
paired. 

Case : Discharge from the right Ear^ with Perforation of the 
Membrane before the Manubrium. — Becovery^ loith formation 
of depressed Cicatrix. — Death in consequence of Phthisis Pulr 
monalis. — Post-mortem Examination of the Ear. 

Mr. N. N., get. 41, civil officer, was admitted into the clinical 
department of Dr. Kolisko, affected with haemoptysis. According 
to his account, he noticed, five years before, for the first time, a dis- 
charge from the right ear accompanied by very slight pain. This 
ceased after some months, but frequently returned after intervals of 
weeks and months. Several months previously the discharge had 
entirely ceased, and since that time also he had no longer noticed 
the whistling of air through the ear upon vigorously blowing the 
nose. The hearing distance in this ear was small during the otor- 
rhoea ; in the intervals it was always better. Tinnitus aurium oc- 
curred only occasionally. 

On examination, we saw in front of and below the manubrium 
(PI. II., Fig. 6) an oval, transparent and therefore dark, depressed 
spot, bounded by light glistening edges. The remaining portions 
of the membrane were tendinous gray, here and there completely 
opaque, and at the place of the cone of light beneath the end of the 
manubrium there was a curved glistening line. The manubrium 
lay horizontally, and appeared bent like a scimitar ; from its pos- 
terior end several vessels ran toward the posterior portion of the 
membrane. The hearing distance for my watch was one foot; for 
the voice, from twenty-seven to thirty feet. An examination of the 
Eustachian tube could not be made on account of the apprehension 
of the patient. 

Post-mortem examination of the right ear revealed the following 
condition : The membrana tympani, with the excej)tion of the parts 
which appeared transparent during life, was dull and opaque, and 
the layers, taken together, thicker by a half than in the normal state, 



Cicatrices — Cases. 109 

yet here and there less thickened and opaque. Nothing could be 
seen of the hyperremia observed during life at the posterior parts 
of the membrane. Before the somewhat curved manubrium was 
the sharply defined elliptical spot mentioned, very thin and of almost 
glassy clearness. Its transverse diameter was two and a half lines ; 
its longitudinal, parallel to the manubrium, amounted to three and a 
half. Compared with the appearance on inspection during life, the 
thin spot was larger than could have been supposed. This is ex- 
plained by the inclination of the membrane to the axis of the 
meatus, as already stated. The lining membrane of the cavity of 
the tympanum and of the Eustachian tube, as well as the covering of 
the auditory ossicles, was smooth. There was no anomalous ad- 
hesion in the cavity, except that the lower end of the long process 
of the incus was closely adherent to the membrana tympani near 
the upper end of the manubrium, whereby the mobility of the 
malleus, as well as of the articulation of the malleus and incus, was 
entirely lost. 

Case : Chronic Inflammation and Ferf oration of the right Mem- 
hrana Tympani. — Recovery., with a formation of athin^ ill-defined 

Cicatrix. 

Mr. S. Gr., set. 35, merchant, from Hungary, states that about 
twelve years ago he experienced severe pain in the right ear, after a 
cold bath in which he plunged from a height. Soon a moderate dis- 
charge from the ear followed, which, after its origin, had very rare 
and short intermissions. Occasionally, severe pain and a disagreeable 
pressure in the ear was experienced ; after violent emotion, subjec- 
tive sounds occurred, ringing and whistling in the ear. 

On examination the membrana tympani (PI. I., Fig. 9) appeared 
uniformly bright red and flattened; at the upper part of the mem- 
brane two yellowish- white flakes of exudation were adherent ; at the 
lower half we saw a round black spot as large as a pin-head, of which 
we could not, at first sight, say whether it was a perforation or a lit- 
tle foreign body upon the membrane. 

To determine this point the Valsalvian experiment was employed, 



110 Membrana Tympani. 

whereupon a small quantity of secretion came out at the black 
spot, soon followed by air-bubbles mixed with, secretion. Thus the 
proof of perforation was supplied. 

The hearing distance for the watch amounted to one foot and a 
half; for the voice, nine feet. The Eustachian tube was easily per- 
vious. 

The treatment consisted in syringing the ear once a day with 
lukewarm water, and subsequent instillation of half a teaspoonful of 
a lotion composed of: Collyr. adstr. luteum 3 ij. ; -Aq. dest. | j. 

After from eight to ten days' employment of this means the dis- 
charge had entirely ceased ; the membrane appeared dry, but dull 
and lustreless ; the handle of the malleus and the short process were 
plainly distinguishable ; the vessels of the manubrium injected, the 
gap in the membrane cicatrized, and the spot was not to be seen. 
The hearing distance amounted to four feet for the watch, and to 
eighteen for the voice. For a disagreeable sensation of dryness and 
itching affecting the external meatus after the discharge had ceased, 
the following application was ordered : ^ Hydrarg. ox. ruh.^ gr. iij. ; 
Ungt. emollient.^ 3 ij. ; Tinct. opii, gtts., iij. M. S. To be applied to 
the meatus with a brush twice a week. 

1 saw the patient again three years later. The discharge had not 
reappeared. The membrana tympani was transparent and glistening ; 
the short process and manubrium clearly marked. At the spot cor- 
responding to the former perforation was an ill-defined depression 
with a diffuse lustre, and perhaps from two to three lines in diameter. 
On the Yalsalvian experiment this rapidly swelled out, and appeared 
very shining and folded, and, after the pressure of air had ceased, 
sank back again just as quickly. 

The hearing distance amounted to six feet for the watch, and to 
forty or fifty for the voice. 

Tlie cases wliere the perforated membrane adheres to 
the inner wall of the tympanic cavity to a greater or less 
extent, by means of cicatricial tissue, are as frequent as 
those which terminate favorably with healing of the per- 



Cicatricial Adhesion. Ill 

foration, as already described. The changes of tlie form 
of tlie membrana tympani occurring in the process of ad- 
hesion are so manifold, and the correct interpretation of 
the appearances so important in diagnosis, that a more 
thorough discussion of the condition certainly seems 
appropriate. 

We have already remarked that in many cases the edges 
of the perforation are so ]3ushed inward that they appear, 
either in part or throughout theii- whole extent, to be in 
contact with the inner wall of the tympanum. This con- 
tact can now give rise, in certain cases, to adhesion of the 
membrane to the promontory, and this adhesion will also 
involve the entire periphery of the perforation, or only 
take place at certain points. Most frequently, in such 
cases, we find the posterior portions of the membrane and 
those lying close above the manubrium adherent, while 
the anterior and lower part stands out free, and distinctly 
separated from the inner wall of the tympanum. In the 
Valsalvian experiment the air whistles through the gap, 
but the adherent parts thereby undergo no change of po- 
sition. 

On the other hand, the appearance is entirely different 
where the edges of the perforation are adherent all 
around to the promontory, and the diagnosis is often 
very difficult. In some cases it is easy to recognize 
the well-defined limit between the adherent edges of 
the perforation and the promontory; in others, how- 
ever, and indeed fi-equently, where the adhesion is of 
long standing, the former edges are no longer distin- 
guishable, since, by the outgrowth of connective tissue 



112 Membrana Tympani. 

from the adherent edges, a cicatrix is formed, which 
covers the free promontory, and unites with it, and no 
line of demarcation between the cicatrix and the remain- 
ing parts of the membrane is visible. 

It is evident that the condition of the membrane varies 
essentially, according to the form and size of the previous 
perforation. The most frequent appearance, with some 
variations, is the following : The short process of the 
malleus is very prominent; extending back from it, as a 
thick gray roll, is the projecting fold of the membrane, 
which normally is but slightly raised. The upper por- 
tions of the manubrium are sharply defined, and it 
distinctly stands out as a yellow band, the membrane 
being greatly retracted on both sides. The lower end of 
the manubrium is strongly drawn in, and is impercepti- 
bly lost in the gray cicatricial tissue lying on the pro- 
montory. The entire malleus handle is, 
consequently, seen in perspective foreshort- 
ening. (See Fig. 6.) The membrane ad- 
herent to the inner wall presents a pecu- 
liar, and, with respect to the diagnosis of 
adhesions, a very noteworthy relation to 
the annulus tympanicus. Thus, for the exj^erienced, it 
vrill be very easy, in cases of this kind, to distinguish 
the annulus tympanicus, either by its strong relief 
from the background, or by the fact that at one por- 
tion of its periphery, most frequently in front and 
below, a sharp border (peripheral portion of the mem- 
brana tympani) rises up, and from it the thickened rem- 
nant of the membrane, blended with the cicatrix, is bent 




Adhesions to the Promontory. 113 

back at an abrapt angle (Fig. 6, «), and extends to the 
promontory at the inferior and lateral walls of the tym- 
panum. The following case presented such an appear- 
ance : — 

Case: Adhesion of Memhrana Tympani to the Promontory after 
Purulent Catarrh of Middle Ear. — Post-mortem Examination. 

Mrs. H. K., set. 42, servant, was received into Dr. Chrastina's 
division, affected with phthisis pulmonalis. In childhood she suffered 
from otorrhoea, which in later years ceased, to return again from 
time to time ; but for twelve years no discharge from the ear had 
been noticed, and dm-ing this period the deafness had gradually 
attained a high degree. The condition of the membrane in the right 
ear was that just described ; in the left, the membrane was mottled 
by irregular deposit of calcareous matter, extending to the periphery. 
The watch was neither heard in contact with the auricle nor through 
the cranial bones. She could not understand conversation a£ all 
upon the left side ; but on the right, if one shouted loudly in her 
ear, she understood everything. The examination of the Eustachian 
tube could not be made, owing to the reduced condition of the 
patient. To convince myself of the correctness of the diagnosis, 
I touched the different points of the background in the right ear very 
cautiously with a blunt-pointed metallic sound, bent at a right angle, 
illuminating the meatus with the reflector held in the left hand. 
The contact of the sound enabled me to recognize quite distinctly a 
firm osseous substratum for several lines about the lower end of 
the manubrium; while, toward the periphery, the parts touched 
seemed yielding and elastic. 

Post-mortem examination of the right ear confirmed, essentially, 
the diagnosis of adhesion of the membrana tympani with the prom- 
ontory by means of a thick cicatrix. Fig. 6 shows us, in vertical 
section through the external meatus and tympanum, the relation of 
the cicatrized membrane to the inner wall. The sharp projection at 
a corresponds to the sickle-shaped band seen, during life, at the 



114 Memhrana Tymjpani, 

anterior lower periphery of the annulus tympanicus, which proved to 
be a stiff, thickened remnant of the peripheral portion of the mem- 
brana tynipani. From this edge the thickened remnant of tlie 
membrane, blended with the cicatrix, extends to the lower and 
lateral parts of the tympanic cavity, to become there firmly united 
to the inner wall. The manubrium, abruptly bent, rests its lower 
end against the inner wall of the tympanum, as the figure shows, 
and the infolding of its end in dense cicatricial tissue explains why 
the malleus handle seemed, on inspection, to pass imperceptibly into 
the gray cicatrix. 

Upon opening the tympanum from above, we found its cavity 
filled with a pale yellow, spongy mass of connective tissue, in which 
the auditory ossicles were completely imbedded. After removal of 
this mass from the upper recess of the tympanic cavity, we could 
not go farther down on account of the adhesion of the upper parts 
of the membrane and the manubrium to the inner wall of the tym- 
panum. Likewise, a sound introduced through the Eustachian tube 
could not be advanced into the tympanic cavity, because the cica- 
trix, extending from the annulus tympanicus in front of the tym- 
panic mouth of the Eustachian tube to the promontory, obstructed 
the passage. The membrana tympani and the cicatricial formation 
were adherent to the promontory to the extent of perhaps three 
and a half lines, and the spongy connective tissue mentioned was 
accumulated between the peripheral parts of the membrane and the 
inner wall of the tympanum. On examination during life, these 
parts were yielding and elastic to the touch of the sound. The 
mobility of the auditory ossicles became much greater after removal 
of the mass of connective tissue. 

From tlie difficulty of making a diagnosis of adhesions 
of the membrane witli the promontory in a considerable 
number of cases, the cautious em]3loyment of the sound, 
as we have used it in the cases just described, seems at all 
events justifiable. We can by no means infer the pres- 



A dhesions — Continued. 115 

enee of adhesions from tlie strong retraction of the 
membrane and of the end of the manubrium, or because 
the depressed spots fail to swell out, even if we observe 
a sharply-defined angle between the peripheral and cen- 
tral parts of the membrane. For such angles by no 
means infrequently occur in long-continued occlusion of 
the Eustachian tube, as well as in chronic catarrh of the 
middle ear, without previous perforation. If the mem- 
brane is thereby much thickened, we shall perceive 
scarcely any, or only a partial swelling out of the mem- 
brane, on forcing air into the cavity of the tympanum. 
In one case of this kind, where, during life, we made 
the diagnosis of adhesion of the membrane to the prom- 
ontory, we found after death no adhesion whatever. 

On the other hand, observations made during life, 
compared with post-mortem conditions, have taught us 
that sometimes even extensive adhesions cannot be 
diagnosticated, especially in those cases where the 
bridge of connective tissue joining the membrane to the 
inner wall of the tympanum is longer than usual, the 
membrane consequently not being much retracted. 
Touching such a spot with the sound would, of course, 
furnish no sure data, since such points, adhering by broad 
bands, are yielding and elastic. 

Ck^^: Former Otorrhoea. — Adhesio?i of the Memhrana Tympani 
to the Inner Wall of the Tympanum by a long cicatricial hand^ 
without Change in the Curvature of the Membrane. — Autopsy. 

Fig. 8, PI. II., is the illustration of the left membrana tympani of 
a woman twenty-five years of age, who died of phthisis pnlmonalis 
in the section of Dr. Scholtz, and who had suffered in her childhood, 



116 Memhrana Tymjpani, 

for several years, from otorrhoea. After its cessation considerable 
deafness remained, which, in the course of time, still increased, so 
that upon this side, in the examination, she heard the watch neither 
when laid upon the ear nor through the cranial bones, and in loud 
speaking near the ear distinguished only the sound of the voice. 
On inspection of the membrane, the short process of the malleus 
was distinctly seen anteriorly and above, but the manubrium was 
covered by a brown pigmentary deposit which extended over the 
greater part of the membrane, while grayish-white irregular opacities 
mottled the peripheral parts. An examination of the Eustachian 
tube could not be obtained. The post-mortem examination showed 
the external layer of the membrana tympani colored to an ex- 
tent corresponding to the appearances shown in the illustration. 
The pigmented spots proved to be, chiefly, cicatricial tissue, 
while at the peripheral parts we could still distinguish the layers 
of the membrane, though opaque and thickened. No line of 
demarcation between cicatricial and normal tissue could be dis- 
covered. On blowing air through the Eustachian tube, we observed 
no motion of the membrane. After removal of the upper wall of 
the tympanum, its mucous lining appeared five or six times the 
normal thickness; and, removing this, we found the upper recess 
of the cavity of the tympanum partially filled with a transparent, 
brown fluid, changeable from the presence of crystals of eholesterine. 
When this was removed, the auditory ossicles appeared imbedded 
in the mucous membrane, likewise much thickened and deeply 
pigmented, and from it the head of the malleus and the body of 
the incus could with difficulty be separated. The membrana tym- 
pani, from the highest point of its upper edge to the bottom of 
the tympanic cavity, was bound to the inner wall by a colored cica- 
trix, from two to two and a half lines in length, measuring from 
within outward. The ostium tympanicum tuhoe was likewise blocked 
up in the same way, and we could not penetrate into the cavity 
of the tympanum with the sound introduced through the tube. 

Among tlie rare conditions we must number those ad- 



A dhesions — Continued. 117 

Lesions of the membrane to the promontory in which 
the upper remnant, together with the manubrium, is 
connected to the inner wall of the tympanum by a 
thick cicatrix formed at its lower edge, while the lower 
peripheral portion is not adherent, and appears as a 
prominent falciform border. 

Case : Otorrhcea many years before. — Adhesion of the upper rem- 
nant of the Memhrana Tympani with the Promontory. — Autopsy. 
A. L., get. 68, workwoman, was received into the section of Dr. 
Scholtz, affected with cancer of the stomach. She stated that many 
years before she had suffered from otorrhcea, after the cessation of 
which she became deaf, so that at the present she could only hear 
a very loud noise near the ear. There was some cerumen in both 
ears, after the removal of which, we found on the left side an un- 
even, opaque, lustreless membrane, while on the right the con- 
dition was very similar to that adhesion of the membrane with the 
promontory described on page 112 (See Fig. 6). While syringing 
out the cerumen the patient became nauseated, and said that a 
quantity of water had passed into her throat. The diagnosis of 
perforation of the membrane and partial adhesion with the prom- 
ontory was made, and the high degree of deafness was thought 
to have arisen from anchylosis of the ossicles, dependent upon a 
former morbid process. The autopsy showed that, besides a 
considerable thickening of the membrana tympani, the malleus and 
incus were scarcely movable, and the stapes was firmly fixed to 
the fenestra ovalis. The condition of the right 
ear is represented in Fig. Y, a vertical section 
through the meatus and tympanum. The short 
process was very prominent, while the manubri- 
um, with the thickened fibrous upper portion of 
the membrane, was drawn inward, and adhered „ 

to the promontory by a dense cicatrix, which ex- 
tended downward and forward toward the Eustachian tube. The 




118 Membrana Tynupani. 

upper part of the cavity of the tympanum, above the adherent por- 
tions of the membrane, was filled with a caseous mass, consisting of 
epidermic cells, detritus and cholesterine crystals, after the removal 
of which the ossicles, rigid and scarcely movable, came to view. 
At the anterior lower part of the annulus tympanicus there still 
remained a stifi* falciform remnant of the membrane, half a line in 
breadth. The sound, introduced into the Eustachian tube, passed 
with facility out into the external meatus. 

The varieties of adhesion already mentioned differ 
from those in which a thin cicatrix closing the perfora- 
tion lies upon the inner wall of the tympanum, and 
adheres to it, not, as in the previous cases, by dense, but 
by loose connective tissue. This anomaly is very in- 
teresting in a clinical point of view. For instance, just 
as we have seen in the process of closure of the perfora- 
tions of the membrana tympani by thin transparent 
cicatrices, here, also, an outgrowth of connective tissue 
from the edges of the erosion takes place, both in the 
small and larger gaps of the membrane, which, from 
want of elastic resistance, is gradually pushed inward, 
and after long-continued contact unites with the 
promontory. The appearance of the membrane in 
such cases, during life, does not differ at all from that 
of a perforation with sharply defined edges, through 
which we see the pale yellow or somewhat reddish 
promontory (PL II., Fig. 2). On the other hand, if we 
force air into the tympanum by the Valsalvian experi- 
ment, or the air-douche, we at once see a strongly in- 
jected membrane rising up from the promontory, and 
swelling out toward the perforation, and after the 



Adhesions — Continued, 119 

pressure ceases, immediately sinking back again, and 
becoming pale yellow. 

Case : Adhesion of a large Cicatrix of the Memhrana Tympani 
to the Promontory. — Autopsy. 

J. S., set. 26, tailor, was received into the section of Dr. Kolisko, 
affected with tuberculosis of the lungs. He had suffered, when a 
child, from otorrhoea in the left ear, which subsided after several 
years, leaving a considerable degree of deafness. In the right, a 
high degree of deafness, without discharge, had developed itself 
since his thirteenth year. Tinnitus auriuni was always present on 
the right side, on the left occasionally. The hearing distance on the 
left was one inch for the watch, and two and a half feet for the 
voice ; on the right, there was only perception of sound. Percep- 
tion of sound through the cranial bones was wanting on both sides. 
On examination of the left ear, the membrane appeared perforated 
around and beneath the manubrium to the extent of about six lines. 
At the lower and lateral parts of the periphery of the membrane 
its sharply defined remnant was to be seen, from one to one and 
a half lines in breadth, while above a broader portion of the 
membrane adhered to the upper third of the manubrium. The short 
process was prominent, while the lower end of the manubrium ap- 
proached the promontory very closely. Through the gap the pale 
yellow promontory could be seen, glistening with moisture, and at 
the anterior lower part of the field of view a bridge, directly 
perceptible on account of several reflections of light, extended from 
the sharply cut edge of the membrane to the promontory. Du- 
ring the Yalsalvian experiment a uniformly injected membrane sud- 
denly rose up from the promontory toward the perforation. After 
the experiment it fell back and became pale again. The patient 
died of phthisis pulmonalis. 

Fig. 8 illustrates in vertical section, after removal of the pos- 
terior wall of meatus and tympanum, the pathologico-anatomical 
condition of the left ear. We find a very dciicate, folded membrane 




120 Membrana Tympani. 

of connective tissue, extendiDg to the promontory from the sharp 
edges of the perforation below, as well as above 
and at the sides, and spreading out over it. If 
we examine this membrane, which is easily mova- 
ble on the promontory, we find it fastened by 
delicate threads of connective tissue. 
Introducing a sound into the Eustachian tube, in 
Fig. 8. order to reach the cavity of the tympanum, we 

push before it the membrane stretched across the tympanic mouth 
of the tube. A sort of cul-de-sac is thereby formed, and the tym- 
panic cavity separated into three divisions : the middle, communi- 
cating with the external meatus ; the posterior, with the mastoid cells, 
and enclosing the auditory ossicles ; and the anterior, leading to the 
Eustachian tube. This condition readily explains the appearance 
during life. Thus the air driven in through the tube, forcing its way 
between the meshes of the cicatrix adherent to the promontory, 
swelled it out, and the circulation in the vessels of the cicatrix and 
promontory becoming impeded, sudden congestion and injection 
of the cicatrix took place. The ossicles were stiff and scarcely 
movable. Concerning the condition of the right ear, see page 67. 

The pathologico-anatomical condition just described is 
to be regarded as, in reality, a variety of the adhesions 
between cicatrices of the membrane and the promontory 
already mentioned. It is worthy of note, however, 
that even the cul-de-sac-like cicatrix, extending 
from the edges of the perforation to the promontory, 
is sometimes perforated. Thus, I found in a prepara- 
tion taken from a young man, who became deaf after 
long-continued otorrhoea and died of tuberculosis, a con- 
dition similar to that described above, with the excep- 
tion that in the delicate sac, which could easily be 
moved upon the promontory, there was an opening from 



Perforated Cicatrices, 121 

two and a half to three lines in breadth at that part 
lying anteriorly and opposite the mouth of the Eustachian 
tube. This perforation probably arose from the frequent 
impulse of air upon this point in blowing the nose. In 
another case I found a gap two lines in breadth, leading 
into the upper recess of the tympanic cavity, at the up- 
per wall of the sac, which was here adherent to the 
tendon of the tensor tympani. If, now, in a case like 
the one just mentioned, there is an opening three lines in 
breadth opposite the mouth of the Eustachian tube, in 
the Valsalvian experiment the air will pass through the 
middle ear into the external meatus without much im- 
pediment, and the cicatrix will not be lifted from the 
promontory. Only when the opening in the sac is so 
small that the air cannot be forced through except 
against strong resistance, shall we observe, together with 
a loud hissing noise, a swelling out of the cicatrix, loosely 
connected with the promontory. 

These new formations are traversed by several large 
capillaries, and the vessels of the mucous membrane of 
the promontory, usually of a dark bluish red, can also be 
partially seen through them. In one case, I saw very 
distinctly those portions of the long process of the incus 
which were covered by cicatrix and adherent to it, as 
well as a portion of the stapes. 

We have hitherto especially dwelt upon the extensive 
adhesions of the membrane, or its cicatrices, to the inner 
wall of the tympanum. It still remains to say some- 
thing of smaller adhesions, and of the union of the 
membrana tympani to the auditory ossicles. In describ- 



122 Membrana TympanL 

ing the liealing process in case of smaller perforations, 
we have made the fact prominent, that adhesions to the 
inner wall of the tympanum much less frequently occur 
in them than in the healing of larger perforations. But 
if an adhesion results, it is in consequence of continued 
contact between the edges of the perforation and the 
promontory, and after the cessation of the discharge we 
see a sharply defined gap in the opaque, or here and there 
calcified, membrane. From its edges a funnel-shaped 
cicatrix, dotted with reflections of light, extends toward 
the promontory, as is illustrated in Fig. 9, by a vertical 
section through the meatus and tympanum. In other 
cases, the transition from membrane to 
cicatrix is not so sharply defined, and the 
partial adhesion is only marked by a shal- 
low depression. In the former case, adhe- 
sion between the membrana tympani and 
Fig. 9. promontory can be diagnosticated with 

certainty, but it is impossible in the latter. 

With adhesions are to be classed those riband-like 
connecting bridges, which are not unfrequently found 
in normal as well as pathological conditions of the 
ear. In the normal ear these bands, single or multiple, 
and more or less strongly developed, extending from the 
manubrium or membrana tympani inward to the inner 
wall of the middle ear or to the ossicles, must be re- 
garded as relics of the gelatinous connective tissue 
substance which, in the new-born, fills the cavity of the 
tympanum, and often degenerates into pus (V. Troltsch). 
We may infer, since they not unfrequently occur in per- 




Textural Helations of the Cicatn^ices, 123 

sons of normal hearing, tliat as a rule tliey exercise no 
influence on the mobility of the auditory ossicles. I 
could, also, perceive no sensible change in the cui'vature 
of the external surface of the membrana tympani 
where bands of this kind existed in the middle ear. 
This generally holds true also of the bands found in 
diseased ears, concerning which it can never be deter- 
mined that they did not exist before the disease. Only 
in a few preparations could I discover a shallow depres- 
sion on the external surface of the membrane, corre- 
sponding to the attachment of the band. Such depres- 
sions, however, are of no diagnostic value when seen 
upon the living, for slight inequalities are not infre- 
quent on diseased membranse tympani. 

Circumscribed pitted depressions are found, not only 
in limited adhesion of the membrane to the promon- 
tory, but, in cases where it is adherent to a larger ex- 
tent, we also see sharply defined recesses (PL II., Fig. 
12), which result partly from stronger retraction of the 
cicatricial tissue at some points, partly from limited 
atrophy of the slightly yielding substantia propria. 
Furthermore, the unequal separation of the membrane 
from the inner wall has an influence upon the irregular 
depression of certain parts, since, as is well known, the 
central portion of the membrane is nearer the promon- 
tory than the peripheral. 

The relation of the elements of the membrane to the 
cicatricial tissue differs in individual cases. Where the 
perforation is closed by a sharply defined, thin, and de- 
pressed cicatrix, we find, under the microscope, as a rule, 



124 Memhrana Tymjpani, 

tlie elements of tlie substantia propria abruptly termi- 
nating at tlie border of the cicatrix, but liere and there 
extending like prongs into the cicatricial tissue. The 
cicatrix itself arises from the connective tissue of the 
dermoid and mucous layers, but is much more delicate, 
and not separable into laminae. The layer of epithe- 
lium on either side is far more delicate than on the rest 
of the membrane. Only in one case have I seen the 
dermoid layer of the membrane terminate like the 
substantia propria at the edge of the cicatrix, the cica- 
tricial membrane seeming to be formed of the connec- 
tive tissue of the mucous layer. (See Dissections of 
Von Troltsch in Virchow's Archiv, Sect. 16.) 

Where, on the contrary, the remnants of the membrane 
are joined to the promontory by dense and thick cicatri- 
cial tissue, it is sometimes not easy to discover the limit 
between the elements of the membrane and those of the 
cicatrix, since the elements of the substantia propria ex- 
tend into the cicatricial tissue in scattered and irregular 
filaments, terminating at different distances. Sometimes 
the fibres of the membrane are so changed by the morbid 
process that they cannot be distinguished from those of the 
cicatrix. (Concerning the structural changes of the mem- 
brane adherent to the promontory, see pages 52 and 
53.) 

The uppermost epithelial laminae of the cicatrices which 
close the perforations without adhering to the inner wall 
of the cavity are always horny, and the cicatrices are 
consequently dry ; but in those cases in which the cica- 
trices are adherent, the external surface is most frequently 



Changes on the Promontory, 125 

moist, occasionally secreting, tliough sometimes dry after 
a long lapse of time. 

After tlie subsidence of otorrhoea, we liave sometimes 
found upon the promontory cicatricial formations analo- 
gous to those occurring in adhesions, though no union of 
the membrane and the inner wall of the cavity is present. 
Thus, in the course of long-continued oton^hoea, hyper- 
trophy and the formation of new connective tissue in the 
mucous membrane of the promontory not unfrequently 
occur. After the secretion has ceased, the hyperaemia 
and swelling of the softened mucous membrane disap- 
pear, but the newly formed connective tissue still remains, 
as thickened cicatricial structure, to such an extent, in- 
deed, as not only to fill the depressions of the inner wall 
in the neighborhood of the tube, but also the niches of the 
fenestra ovalis and fenestra rotunda. The inner wall 
then has the appearance of an uneven surface, in part of 
a pale yellow color, and in part tendinous gray, with 
glistening spots here and there, and, when the membrane 
is destroyed to its periphery, may be easily mistaken 
at first glance for a thickened and opaque membrana 
tympani, unless we pay attention to the distinctly prom- 
inent, riband-like remnant of the membrane perhaps 
still left, or to the isolated stump of the manubrium pro- 
jecting into the gap, or to the well defined border of the 
annulus tympanicus. In the cases of this kind which I 
have observed, where the membrane was wanting to its 
periphery, the field of view in the background was very 
much larger than it is when the membrane is intact. 
What we have before said respecting the cautious use 



126 Membrana Tympani, 

of metallic sounds bent at riglit angles, is applicable here 
also for determining whether we have before us mem- 
brana tympani or promontory ; yet we can very seldom 
decide that these cicatricial tissues on the promontory 
are not connected, at one or more points, with cicatrices 
extending from the remnants of the membrane along 
the lateral walls in such a way as to be concealed by 
the osseous portions of the external wall of the tympa- 
num, consequently not falling within the compass of 
vision. 

The functional disturbances which occur in conse- 
quence of adhesions between the membrane and the 
inner wall of the tympanum vary greatly, and the degree 
of deafness, as the observations of Toynbee, VonTroltsch, 
Schwartze, and others show, bears no proportion to the 
extent of the adhesion. Here, as follows from the above- 
described dissections, those changes must also be taken 
into account which impair the mobility of the auditory 
ossicles, such as outgrowths of connective tissue, calca- 
reous deposits, and hypertrophied mucous membrane, 
which envelop the ossicles ; the adhesion also of the 
ossicles to each other and to the walls of the cavity, and, 
finally, the changes at the fenestrse of the labyrinth. 

From what has been already said, it is evident how dif- 
ficult the diagnosis of adhesions in the middle ear fre- 
quently is. Yet in a certain class of cases, as the above 
descriptions show, we shall, by inspection of the mem- 
brane, be enabled with certainty to pronounce that diag- 
nosis. We can by no means agree with those pathologists 
who affirm that no further significance can be attached 



Persistence of the Perforation, 127 

to it. On tlie contrary, we are convinced tliat in special 
cases it is essential to tlie prognosis, wliicli plays an 
important part in aural surgery. For even when tlie 
impairment of function is inconsiderable in spite of the 
adhesions, experience teaches that no permanent results 
are obtained by treatment, and that relapses are probable 
in the course of time, even after essential improvement of 
the hearing by the air-douche and by the injection of 
moderately stimulating solutions into the middle ear. 

The process of cicatrization is at an end tvTien the edges 
of the perforation become cicatrized^ the gap remaining. 
Although we especially observe this result where there is 
great loss of substance, extending as far as the annulus 
tympanicus, yet sometimes we also find smaller gaps per- 
sistent. Nevertheless, in some cases I have observed, 
after the subsidence of otorrhoea, perforations from two to 
five lines in diameter, continuing for months, indeed, for 
two years, and subsequently becoming closed by thin cica- 
tricial tissue. 

Fig. 10 is taken fi'om a preparation of the right ear of 
a boy fifteen years old, who died of phthisis pulmonalis 
in the section of Prof. Kolisko. He had 
formerly suffered from a copious discharge 
from the ear, which had, however, ceased 
two years before. On examination the 
membrana tympani presented an oval per- Fig. lo. 
f oration beneath the manubrium, with sharply cut 
edges, into which the end of the manubrium projected 
from above, thus making it kidney-shaped. The mem- 
brane was pearl-gray and faintly lustrous. The manu- 




128 Membrana Tympani, 

brium and short process were plainly visible. The por- 
tion of the mucous membrane of the promontory seen 
through the gap was pale yellow and glistening with 
moisture. On the Valsalvian experiment, with little effort 
the air passed out through the perforation. The hearing 
distance was one foot and a half for my watch, more 
than twenty-four feet for the voice. The post-mortem 
examination showed the membrana tympani moderately 
thickened, the gap kidney-shaped, as mentioned, ^\q lines 
in transverse, and from three to three and a half in verti- 
cal diameter, its edges rounded, at some points covered 
by connective tissue, at others only mth epithelium, after 
the removal of which we could easily separate the indi- 
vidual layers of the membrane."^ The lining of the cav- 
ity of the tympanum was smooth, and the auditory ossi- 
cles, so far as could be determined by the usual rough 
method of examination, appeared somewhat less mova- 
ble than is normal. f 

* Note. — Schwartze states in his "Praktische Beitrage" that large per- 
forations which have existed for a long time, and have thick, sharply cut, or 
especially calcified edges, can by no means be closed. This is a great detri- 
ment to the patient, because the way lies open to new troubles of the mucous 
membrane of the middle ear. 

f Note. — We give here a short abstract of the treatment of purulent catarrh 
of the middle ear with perforation of the membrane. 

If the affection is acute, and comes on with severe pain and febrile movement, 
the membrane and meatus at the same time appear much injected and swollen, 
we apply just in front of the tragus from two or three to five leeches, according 
to the intensity of the symptoms and the general condition of the patient. 
Internally we prescribe, especially at night, from one to three one-twelfth grain 
doses of acetate of morphia. Externally, about the ear we apply twenty 
drops of an embrocation composed of two drachms of oil of almonds 



Note — Purulent Catarrh of Middle Ear, 129 

Witli solutions of continuity in the membrana tym- 
pani and their results, were also described the changes 
which the auditory ossicles thereby undergo. It is neces- 
sary still to mention some rare conditions, which are re- 

and a drachm of chloroform. Warm poultices and cold are equally injurious; 
but, on the contrary, where the pain is very severe before or after the rup- 
ture of the membrane, dropping lukewarm water into the meatus (Yon 
Troltsch) sometimes proves very beneficial. If alarming symptoms appear, 
such as convulsions or great mental confusion, leading us to infer an accumu- 
lation of pus in the middle ear, and we find the membrane at one point green- 
ish-yellow and swelled out, we perform paracentesis with a rather large cata- 
ract-needle, in order to provide an exit for the pus. 

If otorrhoea has come on, we syringe the ear with lukewarm water from two 
to four times a day, according to the amount of discharge. If the secretion 
has a penetrating odor, we add to the tepid water a little aqua chlorata, about 
a teaspoonful to half a tumblerful of water, or a weak solution of chloride of 
lime, one scruple to six ounces of water, two tablespoonfuls of which is to be 
added to half a tumblerful of water. 

Of the astringents employed in otorrhoea, the following have proved 
most efl&cacious: '^ Zinci Sulphat grs. ij-v. Aq. Dest.,'^]. M. S. Morning 
and evening, pour in a teaspoonful and allow it to remain ten minutes. ]$ 
Tlnd. Ferri Muriat. ^*-iij. Aq. Best. 5j. M. S. Use as above. 1^ Plumhi 
Acetat. grs. ij-v. Aq. Best. | j. M. S. Use as above. 5 Acidi Tannici, grs. 
iij. Aq. Best. | j. M. S. Use as above. Alum and nitrate of silver do not 
act as favorably. The astringent decoctions of bark are to be wholly rejected. 

If these agents have been employed in special cases without essential ben- 
efit, the following preparations of zinc may still be prescribed: 5 Zinci Ace- 
tat grs. j-iij. Aq. Best. |j. M. S. To be dropped in. '^ Collyrii Ads 
Z2^i(.TTl_xv.-3 j. Aq. Best. |j. M. S. To be dropped in. 

The pus is best removed from the meatus by syringing; but as that in the 
recesses of the cavity of the tympanum is not reached by the stream of water, 
and consequently by its stagnation the suppuration is kept up, and, moreover, 
through calcification may give rise to anchylosis and fixation of the ossicles, 
it is therefore necesssary, in order to cleanse the cavity of secretion, that we 
should from time to time force a strong current of air into it through the 
Eustachian tube. This is best accomplished in the manner already described ; 

9 



130 Membrana Tymjpani, 

cognizable on inspection, and full of interest as regards 
diagnosis. 

Here, first of all, belongs the separation of the manu- 
hrium from the membrana tym/pani^ an anomaly repeat- 

and this method, moreover, may be employed at the same time to bring the 
astringent solution fully into contact with the mucous membrane of the cav- 
ity of the tympanum. 

For this purpose, while the patient sits with the head inclined, we fill the 
meatus with a lukewarm solution of sulphate of zinc, from two to four grains 
in half an ounce of distilled water, and, if both ears are affected, the meatus 
which is filled being closed by the patient's finger, the other is filled with the 
same solution, and the air forced into both cavities during the act of swallow- 
ing, in the manner before described. The air which now passes through the 
tympanic cavities appears in the passages, filled with the solution, in the form of 
bubbles, and, simultaneously with its escape, the fluid enters the cavity of the 
tympanum through the perforation. This often takes place so quickly that the 
fluid runs through the Eustachian tube into the throat during the experiment. 
It must be explicitly stated that for this purpose we employ only the sulphate 
or acetate of zinc, because they form no adherent precipitate, as do acetate 
of lead or muriate of iron. This method of treatment is practised three 
times a week for several weeks, and after an intermission of several weeks or 
months is renewed again. 

Yegetations in the external meatus, on the membrana tympani, or the prom- 
ontory, which so long as they remain keep up the otorrhoea, must be removed 
when they can be easily reached, or destroyed by touching with a concentrated 
solution of muriate of iron, or, if hard, by nitrate of silver in substance. We 
employ for the latter a simple metallic wire of the length of a sound, bent 
at right angles at the middle, immersing the point several times in nitrate 
of silver, melted in a little porcelain cup, till the caustic has hardened upon it 
in the form of a little ball. 

If, in given cases, it is a question as to the indication for an artificial drum, 
everything which temporarily reduces the hearing power must first be re- 
moved. Thus, in the first place, in order to free the tympanic cavity of puru- 
lent secretion, we must force air through it either by introducing a catheter 
into the Eustachian tube, or, better and more simply, by the method devised 
by me, driving the pus partly back into the mastoid cells, and partly 



Detachment of the Manuhrmm, 131 

edly mentioned by Toynbee in his "Descriptive Cata- 
logue " of his patliolo£!;ico-anatomical collection, as well 
as in his Diseases of the Ear (German translation by Moos 
of Heidelberg). I have observed it in three cases, and 
in one instance the diagnosis made during life corre- 
sponded with the post-mortem condition. In the ex- 
amination of such a membrane, we see the pale yellow 

through the perforation into the external meatus, whence it will then be re- 
moved by syringing. Then we proceed to determine the hearing distance 
both for the watch and for the voice. After this the auricle is drawn some- 
what backward and upward with the left hand, in order to make the meatus 
as straight as possible, and the moistened artificial membrane introduced with 
the right hand. We shall generally meet with some slight resistance disagree- 
able to the patient at the middle of the meatus, on account of its narrowness. 
But in spite of this, the membrane can easily be carried to the end of the 
meatus. If the patient immediately experiences marked improvement in 
hearing, or complains of pain on pressing it further in, we must at once abstain 
from any further effort to carry it deeper, and with the speculum ascertain 
the condition of things at the bottom of the meatus. If the trial made after 
this shows no (or only insignificant) improvement of hearing, we must not 
abstain from further attempt^ but by slight turning or new introduction of the 
instrument give another position to the little plate of rubber, by which chano-e 
we shall not unfrequently obtain astonishing improvement. 

I have in my charity practice introduced a modification of the artificial 
membrane, which in effect fully supplies the place of Toynbee's. The prepara- 
tion of this little apparatus is so ea^y that any practitioner may readily under- 
take it, and the price of the materials for a hundred is so very trifling that it 
is hardly worth taking into account in the single pieces. Thu,*, I cut out of 
the sides of a thick india rubber tube little pieces from four to five lines long, 
and from one and a half to two in thickness, the lower end somewhat broader 
than the upper. These are perforated and fastened to a moderately stout 
wire. The method of introduction and apphcation is just the same as with 
Toynbee's artificial membrane. - It is also necessary, in special cases, to bend 
the end of the wire in such a manner that the instrument shall remain in the 
position in which it was placed and not fall out. 



132 Memhrana Tynvpani, 

line, whicli indicates the course of the manubrium, in- 
terrupted at a point near the middle or above it, so that 
only the upper portion of the manubrium is visible. This 
visible portion either abruptly terminates at its lower 
part or is gradually lost upon the membrane, as Fig. 
5, PL II., illustrates. The umbo is usually flattened, 
and we find the membrane either only moderately 
opaque, or calcified in spots, or having circumscribed 
attenuated areas. The occurrence of separation of 
the lower part of the manubrium is especially favored 
by the traction of the tensor tympani. In inflammatory 
conditions of the membrana tympani, which result in 
loosening and softening of its tissue, separation of the 
manubrium by the traction of the membrane is conceiv- 
able, and this takes place all the more readily when the 
portions of the membrane surrounding the malleus 
handle are partly destroyed. The manubrium is then, 
as was mentioned in case of perforations, drawn inward ; 
and while the breach in the membrane cicatrizes, the 
lower portion of the manubrium remains in its position 
inclined inward, without being enveloped 
in the cicatrix. On opening the tympa- 
num, we consequently find the handle, like 
a blunt rounded cone, projecting free into 
Fig. 11. the cavity, or a bridge extends from it to 
the membrane, whereby it presents in profile the appear- 
ance of a nose, as the vertical section through the meatus 
and tympanum in Fig. 11 illustrates. Whether this 
separation of the manubrium occurs also in affections 
which run their course without perforation of the mem- 




Fracture of tlie Manubrium. l'^3 

"brane, is left entirely to conjecture, for tlie proof is yet 
to be supplied. 

As another anomaly properly belonging here fracture 
of the manubrium is worthy of mention. 

The few observations already made were, together 
with one of his own, mentioned by Yon Troltsch in his 
"Diseases of the Ear," page 73. He says, "Meniere 
(Gaz. M^dicale, 1856) reports such an observation, in the 
case of a gardener who, accidentally falling, thrust a 
twig of a pear tree into his ear. There was very exten- 
sive laceration of the membrane, and the several parts of 
the malleus, with the remnants of the membrane to which 
they were attached, could be plainly seen to move. The 
healing of this remarkable lesion occurred without any 
special aid from art." I have myself seen one case of 
fracture of the manubrium. A wine-merchant, in cross- 
ing his court, was scratching his right ear with a pen- 
holder, when his elbow unexpectedly struck a door, 
which stood open, driving the pen-holder deep into 
the ear. With a sharp cry of pain he fell do^^Ti 
fainting, and did not revive for some minutes. As cold 
water was immediately poured into his ear, he can- 
not tell whether there was any hemorrhage. Since 
then he has heard badly, and suffers from constant ring- 
ing, especially when he lies upon the right side. When I 
saw the case a year later, I was struck with the peculiar 
distorted position of the manubrium, which at one point, 
close beneath the short process, appeared unusually 
thick and prominent, and from this point out, as it were, 
twisted upon its axis. In short, I was convinced that 



134 Membrana Tympani. 

the condition could only be the result of a united 
fracture of the handle of the malleus. Hyrtl also has 
very recently described such a united fracture (Wiener 
med. Wochenschrift, 1862, 11). He found it in the ear 
of a prairie dog (^Arctomys ludovicianus) ^ also close 
beneath the neck of the malleus, and having a pre- 
cisely similar appearance. He adds, that such a lesion is 
not to be wondered at, since this animal, a congener of 
our marmot, lives principally in holes underg]-ound, and 
on account of the shortness of the meatus its membrana 
tympani is very superficial. 

Among the less frequent conditions of the membrana 
tympani are further to be classed the adhesions of the 
membrane^ or of a cicat/rix in the membrane, to the 
stajpes. Troltsch {loc, cit.) gives an accurate description 
of this condition, and Toynbee's collection of pathologico- 
anatomical preparations of the ear contains several spe- 
cimens in which this anomaly is present. With regard 
to these conditions, the adhesion appears to occur espe- 
cially after the subsidence of otorrhoea, since a yielding 
of the articulation of the incus and stapes results from 
the inflammatory process, and the membrana tympani, 
usually thinned or patched at points with thin cica- 
tricial tissue, is pressed inward and lies against the 
inner wall of the tympanum, and after continued contact 
unites with the head and crura of the stapes. Whether 
adhesions of this kind, between the membrane and stapes, 
also occur without preceding otorrhoea, further observa- 
tions must determine. 

If one only has some anatomical knowledge of the 



Adhesion to Stapes, 135 

ear it will not be difficult, even if lie is inexperienced, 
to interpret tlie condition of tlie membrane in this 
anomaly. We discover, for instance, at tlie posterior 
portion of the membrane (PL II., Fig. 7) an outline 
which, from its peculiar form, is at once recognized as 
corresponding to the parts of the stapes. The head of 
the stapes is usually turned downward, while its two 
crura are directed upward and. somewhat backward. It 
is worthy of note, that on inspection the outline of the 
stapes cannot always be seen at the periphery of the 
the posterior upper quadrant, as it would be in order to 
correspond mth its anatomical position, but frequently 
(as in PL II., Fig. 7) further doT\Ti. Indeed, the outline 
of the stapes may be seen in front of the malleus handle, 
if, after the dislocation of the ossicles, the anterior por- 
tion of the membrane unites with the stapes, as I saw it 
in one preparation to be found in Toynbee's collection. 

Fig. 7, PL II., is a representation of the left membrana 
tympani of a girl eighteen years old, who had an otor- 
rhoea with perforation of the membrane upon the right 
side, but had noticed no purulent discharge upon the 
left. In looking at the membrane, we found the short 
process of the malleus, as well as the upper part of the 
manubrium, very prominent, while the lower end was 
di'a^vn inward. Behind the manubrium an outline was 
visible upon the membrane, corresponding to the head 
and upturned crui^a of the stapes. The membrane was 
very thin, transparent^ and uneven, with here and there 
large irregular reflections of light upon it. Upon for- 
cing air into the tympanic cavity, certain portions of the 



136 Memhrana Tympaiii. 

membrane stood out more prominently ; tlie reflections 
altered tlieir form and size, while tlie visible portions of 
the stapes did not change their shape, thus proving that 
the membrane was adherent to them. The hearing dis- 
tance on this side varied, yet sometimes amounted to 
seventy -five or eighty feet for the voice. The transmis- 
sion of sound from the membrane to the labyrinth was 
effected by the stapes alone, without the intervention of 
the malleus and incus ; and hence this anomaly is analo- 
gous to the sound-conducting apparatus of birds, where, 
as is well known, the transmission from the membrane 
to the labyrinth is accomplished by a single auditory 
ossicle, the colhimella (stapes). 

With the preceding cases we class as rare those con- 
ditions in which a portion of the upper wall of the ex- 
ternal meatus has heen ahsorhed in the course of an 
otorrhoea, and after cessation of the secretion the head 
of the malleus and body of the incus, lying in the upper 
recess of the cavity of the tympanum, have become 
visible ; or, if these are destroyed, those portions of the 
inner wall are seen which normally are hidden by the 
osseous meatus. The very large extent of illuminated 
background is characteristic of these anomalies. 

Fig. 12, PL 11. , is taken from the membrane of a prep- 
aration which, from its rarity, is worthy of descrip- 
tion, although the person affected was not under ob- 
servation during life. On illuminating the background, 
we notice at once the large extent of the field of view. 
Toward the upper part of the field we see a large 
yellowish body with processes. It is the head of the 



Rare Cases. 137 

malleus connected witli the body of tlie incus, together 
with the processes of the incus and the handle of the 
malleus. Beneath this appear several pitted depres- 
sions of varying size, one of which, at the lower part of 
the field, is remarkable for its extent. The upper wall 
of the meatus is so thinned by atrophy that only its 
upper lamella remains. The meatus consequently ap- 
pears wide, and the auditory ossicles, which normally are 
masked by the thick wall of the meatus, now lie open 
to view. On removing the upper wall of the tympanum, 
we found the head of the malleus forming a bony union 
with it, but the incus free and somewhat movable at 
the articulation with the malleus. The malleus and incus, 
as well as the membrane, are united to the inner wall 
of the tympanum by bands of connective tissue, which 
are tense at some points and loose at others, thus giving 
rise to the irregular pitted depressions. 

I found an essentially different condition of the mem- 
brane in the left ear of a Polish merchant, thirty-six 
years of age. From childhood he had suffered from 
otorrhoea, which, however, had ceased four years before. 
Being consulted on account of difficulty of hearing in 
the left ear, I found the meatus filled with cerumen, 
after the removal of which, the hearing distance rose 
from one to four inches for the watch, from six to 
twenty-four feet for the voice. On inspection of the 
membrane, it appeared somewhat flattened and slightly 
opaque. The short process of the malleus and the manu- 
brium were distinctly marked and in normal position. 
Above the upper border of the membrana tympani, which 



138 Membrana Tymjpani, 

was separated from its osseous insertion to tlie extent of 
six or seven lines, I observed a loss of substance in tlie 
osseous meatus, through whicli the glistening gray- 
lining of the cavity of the tympanum could be seen. 
Singularly, however, through the gap, whose lower edge 
was formed by that portion of the periphery of the mem- 
brane lying above and to the side of the short process 
of the malleus, nothing could be seen of the head of 
the malleus or of the body of the incus — a fact which 
could only be accounted for by a partial destruction and 
extrusion of these ossicles. 



ANOMALIES 

IN THE CUKVATUKE OF THE MEMBRANA 

TYMPANI. 

Besides tlie changes described, affecting tlie color 
and transparency as well as coherence of the membrana 
tympani in diseases of the ear, its curvature also under- 
goes many variations, which are of essential impor- 
tance with reference to diagnosis. We have already be- 
come acquainted with a large class of such changes 
among the anomalies discussed in the previous sections ; 
and we turn now to the consideration of another series 
of observations, describing abnormal convexity, the con- 
ditions, first, of outward, and then of abnormal concavity. 

The external convexity of the membrane seldom aiffects 
it throughout its entire extent. I have observed this only 
in cases of very severe acute catarrh of the middle ear^ with 
simnltaneou'i inflammation and swelling of the tvhole 
m^emhrane^ which appeared arched out like a globe, had 
a bluish-red suffusion, and glistened with moisture. 
Such globular convexities differ little in outward appear- 
ance from certain forms of polypi which grow out of the 
cavity of the tympanum. These vegetations, however, 
are excluded by the short duration of the affection in the 
cases before us. As a rule, these protrusions continue 
only for a short time, since, with the disappearance of 



140 Merribrana Tympani, 

the inflammatory symptoms, tlie swelling also rapidly 
subsides, tlie membrane becomes flattened, and, thougli 
still much injected and covered with softened epidermis, 
the redness gradually passes away, the short process and 
manubrium come to view, and the membrane may either 
return to the normal state, or opacities of varying degree 
still remain, or ruptures of the membrane may take place 
before the swelling subsides, upon which it sinks down 
and becomes flattened. 

• More frequently the protrusions of the membrane are 
limited. Both in acute inflammation of tlie membrane^ 
and also in acute catarrh of tlie middle ea/r^ we not unfre- 
quently find the upper half of the membrane strongly 
arching out, of a dark bluish-red color, and covered with 
a thin layer of gray, cracked epithelium. The manubrium 
and short process are invisible. The lower part of the 
membrane, however, has undergone no change of curva- 
ture, and in contrast with the bulging upper portion, 
appears very much in the background. The convexity 
often disappears after only a day's duration, and, then, 
the changes which afterwards occur are analogous to the 
appearances we have already mentioned (page 42) in 
the description of acute catarrh. 

Abscesses in the membrane also appear as circumscribed 
convexities. They are among the rare conditions of the 
membrane, and are developed in the course of acute my- 
ringitis, or acute catarrh of the middle ear. Wilde saw 
circumscribed collections of pus in two cases. Upon 
opening one with a cataract needle, pus was discharged 
into the meatus. Von Troltsch observed, at the upper 



Abscesses. 141 

edge of the membrane in a case of acute myringitis, a 
tumor as large as a hemp-seed, yellowish, and doughy to 
the touch, which gradually diminished as the inflammation 
subsided. Schwartze saw abscesses occur after touching 
the membrane with a solution of nitrate of silver. In 
one case of acute catarrh of the middle ear, I observed 
three greenish pustules of the size of a poppy-seed along 
the manubrium, surrounded by a red areola. They 
disappeared after two days without leaving a trace 
behind. In one other case, I saw, in the com*se of the 
same disease, on the third day, an ill-defined, greenish- 
yellow swelling behind the manubrium, about the size 
of a small pea. The vessels of the manubrium were in- 
jected ; otherwise, the membrane was little changed, ex- 
cept that the lustre was somewhat faded. The following 
day, on examining the membrane, nothing could be seen 
of the circumscribed swelling, and not until the examina- 
tion had continued for some time did the spot designated 
swell out again, and appear of the same extent and color 
as on the preceding day. This puzzling phenomenon 
appeared again on the next day, but not afterwards. It 
was observed, at the same time with myself, by several 
of those attending my lectures. 

I have, moreover, observed the formation of abscesses 
in the membrana tympani during acute purulent catarrh 
of the middle ear. Yet, although interstitial abscesses 
doubtless occur simultaneously with acute suppuration of 
the mucous lining of the tympanum, still it is very difil- 
cult to determine, in such cases, whether a greenish 
circumscribed protrusion on the membrane proceeds 



142 Memhrana Tympam. 

from an abscess in its substance, or from an accumulation 
of pus in the cavity of the tympanum. In one case of 
simple acute catarrh of the middle ear, I observed on the 
injected and swollen membrane several vesicles of the 
size of a millet-seed, filled with a fluid of a watery trans- 
parency. They had already disappeared upon the fol- 
lowing day. 

The external surface of the membrane, in many cases, 
undergoes a change of curvature from the formation of 
granulations upon it. They arise in the course of chronic 
otorrhoea with perforation of the membrane, and but very 
seldom m chronic otitis externa without lesions of the 
membrane. They are papillary vegetations of the con- 
nective tissue of the dermoid layer of the membrana tym- 
pani, and appear either singly or in groups, or scattered 
in larger numbers over the entire surface. We see, 
therefore, upon the dirty gray or greenish-yellow mem- 
brane, which is injected and swollen, one or more 
fleshy excrescences from the size of a millet seed to that 
of a hemp seed. If its surface is covered with vegeta- 
tions, the membrane appears like a raspberry — bluish-red, 
and dotted with numerous light spots. Occasionally simi- 
lar vegetations are simultaneously visible upon the osse- 
ous portion of the external meatus. 

The diagnosis of granulations of the membrana tym- 
pani can be made with certainty in one class of cases, 
where, together with the vegetations, we discover a perfo- 
ration from which pus, or, upon forcing air into the tym- 
panic cavity, bubbles come out ; or where the opening 
on the granulated surface becomes visible by the separa- 



Granulations — Polypi, 143 

tion of its lips tlirougli tlie pressure of air. Yet, not un- 
freqiiently it is so concealed by one or more vegetations, 
that, even on forcing in air, nothing can be seen of an 
opening though we distinctly hear the air hissing through 
it. In such cases it is very difficult to distinguish between 
vegetations on the membrane and those upon the inner 
wall of the tympanum, extending out to the level of the 
membrane (see page 86). Even the change of the posi- 
tion of the light spot, or of the curvature of the granu- 
lating surface, on forcing air into the middle ear, is not 
decisive proof that we have a granulating membrana 
tympani before us, since, as has been stated, these 
phenomena are observed also on the softened and hyper 
trophied mucous membrane of the cavity of the tympanum 
In like manner, a polypus at the bottom of the meatus 
growing out of the cavity, and having a warty surface 
may easily be mistaken for a softened and glandulous mem 
brana tympani. Since the diagnosis in such cases is of 
great importance with reference to the treatment to be 
employed, we should, when inspection is not decisive, 
make an examination with a sound bent at right angles. 
If we succeed in carrying the sound around the growth 
by cautiously pushing along the edges, and showing it to 
be easily movable, the diagnosis of polypus is thereby 
confirmed ; though even then we cannot always say mth 
certainty whether it arises from the external or the 
middle ear, or, as very rarely happens, from the mem- 
brana tympani itself. In one class of cases, however, the 
diagnosis cannot be made at all, or is first established in 
■!;he course of changes which are decisive with respect to it. 



144 Membrana Tyrrijpani, 

The vegetations on tlie membrana tympani sometimes 
disappear spontaneously, or after frequent cleansing of 
the meatus and the use of astringent washes, especially 
the solutions of sulphate of zinc and tincture of the muri- 
ate of iron. In several cases, painting the hypertrophied 
surface with concentrated tincture of the muriate of iron 
was followed by decided improvement ; but in others it 
was ineffectual, and the granulations could only be re- 
moved by fi-equent applications of nitrate of silver in 
substance. 

In case of a young man who had suffered from otor- 
rhoea for eight years, the membrana tympani was studded 
with numerous little warts, dark red, and very shining 
(PL I., Fig. 7). During the Valsalvian experiment we 
heard the air whistle through, and saw several air-bubbles 
appear on the background without being able to discover 
any opening. The hearing distance for my watch was 
four inches, and more than four feet for the voice. The 
air-douche made no change in it. By six applications 
of the caustic employed every third day, the vegetations 
were removed, and a perforation of the size of a pin- 
head appeared below the manubrium, the secretion 
ceased, the short process and the manubrium became 
visible, and the membrane had an irregular grayish 
opacity. After some days the opening cicatrized, and 
the hearing distance, steadily improving during treat- 
ment, was quite normal in ten days. 

With the circumscribed protrusions of the membrana 
tympani are also to be classed those hleh-like promi- 
nences which, in many cases of chronic disease of the 



A trophy — Hernia. 145 

middle ear, come to view iipon the employment of tlie 
air-doiiclie, arising either in consequence of a partial 
loss of substance in tlie mucous and fibrous layers, 
tlie air accumulating beneath the dermoid layer (Von 
Troltsch), or from hernial protrusion of the mucous 
membrane between the separated or absorbed fibres of 
the substantia propria. The former was first observed 
by Von Troltsch (Krankheiten des Ohrs, p. 92) at the 
posterior upper portion of the membrane, where a 
pretty large uneven protrusion swelled out into the 
meatus, projecting down over the end of the manu- 
brium, and as it were covering it. After a short 
time these protrusions disappear again. From my 
own observations I can confirm the statements of 
Von Troltsch, and will further mention a condition 
which argues that these bubble-like swellings may arise 
also from hernial protrusions of the mucous layer. In 
a man who was consumptive and hard of hearing, and 
upon whom the air-douche could not be employed, there 
were diffuse opacities on the right membrana tympani, 
but no anomalies of curvature. In the post-mortem 
examination I observed a thin-walled bubble, of the size 
of a small pea, appearing upon the external surface of the 
membrana tympani, behind the manubrium, on forcing 
air through the Eustachian tube. This again became 
smaller and disappeared when I rarefied the air in the 
middle ear. Upon opening the tympanum, the mucous 
membrane, at the point, of the inner surface correspond- 
ing to the protrusion, projected into the cavity of the 

tympanum in the form of a wrinkled cone, and closer 

10 



146 Membrana Tympani. 

examination showed the fibres of the substantia propria 
separated from each other, and the mucous membrane, 
with the adherent dermoid tissue, attenuated and folded 
together in the manner described. 

Besides the pathological changes in the membrana 
tympani already mentioned, there are protrusions at 
points upon it, the result of interstitial exudation, of 
accumulations of pus and mucus in the cavity (see page 
95), and of polypoid growths in it. In one case I saw 
the membrane forced outward by the accumulation in 
the cavity of an inspissated, cheesy mass of epidermis. 
So manifold are the diversities of condition which an 
examination in all these changes furnishes, that a de- 
tailed description must evidently be regarded as im- 
practicable. Only a knowledge of the normal and 
morbid anatomy of the ear, and an accurate compre- 
hension of the course of the disease, will here, in many 
cases, lead to a correct diagnosis. When, therefore. Dr. 
W. Kramer, privy sanitary counsellor in Berlin, char- 
acterizes the results obtained by the study of the 
physiology and pathological anatomy of the ear as 
wholly useless in aural surgery, we must pity the man 
who, grown gray under constant opposition and strife, 
has, by his unremitting outbursts of rage against the 
recent progress of aural surgery, gained a truly un- 
enviable name in the annals of science. 

We meet with abnormal inward curvature of the 
membrane still more frequently than with external cur- 
vature. It affects either the entire membrane, or in- 



I 



Abnormal Concavity, 147 

dividual parts of it. Most frequently we find tlie wliole 
membrane pressed inward in long continued occlusion of 
tlie Eustacliian tube, in consequence of wliicli tbe air in 
tlie cavity of tlie tympanum is absorbed, and the mem- 
brane forced in by atmospheric pressure. Yet I be- 
lieve tliat we should call attention to another factor, in 
this case having an essential influence upon the inward 
curvature of the membrane. It is the secondary retrac- 
tion of tlie tendon of tlie tensor tyiwpani. If, for instance, 
the membrane is strongly pressed inward, the point of 
insertion of the tendon upon the manubrium must also 
approach the inner wall of the tympanum. The tendon, 
previously stretched, now becomes slack, and since its 
antagonizing force, the tension of the elastic membrane, 
is partially overcome by the atmospheric pressure, 
it will contract in the same way — to use a compari- 
son — as the tendons of the flexors of the leg, when 
it has been bent at the knee-joint for a long time. 
Evidently, such a shortening of the tendon may still 
further increase the inward curvature of the membrane, 
and on longer continuance, even when the permeability 
of the Eustachian tube and the balance between the 
pressure of the external and internal air are restored, 
may still always act as an abnormal inward traction ; 
and, consequently, it is obvious that disturbances of 
function of varying degree may also occur, from the 
strong pressure exercised upon the chain of ossicles, and 
through them upon the labyrinth. 

If the inward curvature of the membrane has continued 
for a long time, it loses a part of its elasticity; since 



148 Membrana Tympani. 

by the constant stretcliing an atrophied condition (Von 
Troltsch) is developed, especially in the substantia pro- 
pria. The membrane becomes thin and lax, and the dis- 
proportion between its tension and that of the auditory ossi- 
cles must lead to disturbance in the transmission of sound. 

In chronic catarrh of the middle ear, without occlu- 
sion of the Eustachian tube, we have also not unfre- 
quently observed marked concavity of the membrana 
tympani. It results, according to Von Troltsch, either 
from adhesion of the membrane to the inner wall of the 
tympanum, or from peripheral thickening of its mucous 
layer. Yet it cannot be doubted, and repeated dissec- 
tions have taught me, that in chronic thickening of 
the mucous membrane of the cavity, a shortening of 
the tendon of the tensor tympani, by retraction of its 
thickened mucous covering, may, not unfrequently, 
cause a concavity of the membrane. 

In discussing the normal relations of curvature and 
inclination of the membrane, we have already said that 
our judgment in respect to them is not reliable. This 
holds good also, in part, of the relations of curvature 
in morbid conditions of the membrane ; nevertheless, 
there are certain data by which we are able, generally, 
to determine an abnormal change of curvature, even if 
we cannot accurately measure its degree. In the first 
place, the inclination of the lower end of the manubrium 
inward is marked, and therefore also the apparent 
shortening of the whole handle (PL I., Fig 10). In 
consequence of this inclination of the manubrium, the 
short process of the malleus (which is upon the upper 



Abnormal Concavity : Color — Lust/re, 149 

arm of the lever formed by tlie malleus) stands out 
more prominently, and causes a more marked projection 
of the parts of the membrane lying next to it, in the 
form of two folds (Von Troltsch). 

The anterior fold is usually not very prominent. The 
posterior extends, like a roll, from the projecting short 
process along the upper border of the membrane back- 
ward, and may be easily mistaken by the inexperienced 
for the manubrium, especially if the malleus handle is 
so hidden by the posterior part of the membrane that 
either it cannot be seen at all, or only at its lower end. 

Since the membrane approaches the inner wall of the 
tympanum, it not unfrequently comes in contact with 
the long process of the incus, which we see as a short, 
frequently prominent band, behind the manubrium. The 
chorda tympani and the pocket of Troltsch not unfre- 
quently, in these cases, lie very close to the membrane, 
and show through it. 

The coloj' of the membrana tympani, in inward cur- 
vature resulting fi^om tubal obstruction, is quite un- 
changed, or it is dark violet where there is simultaneous 
injection of the mucous coat of the membrane or pro- 
montory. In one class of cases, however, it presents a 
peculiar dark-gray and dusky aspect. In catarrh of the 
middle ear of long standing, we usually find the tendi- 
nous gray, striated opacities already described. 

The lustre of the membrana tympani undergoes im- 
portant changes. The soft diffuse gleam often appears 
remarkably heightened ; the cone of light, from the 
change of curvature, loses its previous form, and is seen 



150 Memhrana Tympani. 

in tlie \dcimty of the umbo as an irregular, faint, light 
spot. We must notice as of imjDortance a bright linear 
stripe in the neighborhood of the cone of light, fre- 
quently observed in tubal catarrhs. This stripe is some- 
times connected at one point with the light spot in front 
of the umbo, but is longer than the normal breadth of 
the cone of light. It is traced upon an edge which is 
formed near the periphery of the membrane by a sharp 
depression of the central portion of the membrane. 
The peripheral portion of the membrane, through aggrega- 
tion of the circular fibres of the substantia propria, pos- 
sesses, for the width of perhaps a line, a far greater power 
of resistance than the central portion where the elastic 
elements are less abundant. The central part mil 
therefore yield more to the pressure of the external air, 
and consequently move further inward than the periph- 
eral, whereby a sharp angle is formed, 
usually at the anterior lower jDart of the 
membrane, as is shown in Fig. 12 (see pages 
68 and 69). 

Fig. 12. These angles of the central portion of mem- 

brane occur, though very rarely, in persons of normal hear- 
ing. Sometimes I have found them upon normal mem- 
branes in post-mortem examinations of children ; twice in 
adhesions of the membrane with the promontory. We 
have already described in detail the anomalies of curva- 
ture in adhesions of the membrane, when speaking of the 
healing process of perforations, but will remark further, 
that, according to our experience, adhesions of the mem- 
brane with the promontory are rare in catarrhs that run 





Circumscribed Degression. 151 

their course without suppuration and perforation — mucli 
more so than has hitherto been supposed. 

If we observe the changes taking pLace in these 
inward cui'vatures of the membrane during the air- 
douche, we shall find that in one class of cases the mem- 
brane at once makes a considerable movement outward, 
while in others we shall either perceive no motion at all, 
or only very slight. Even where a complete restoration 
of the hearing power results after removal of the affec- 
tion of the middle ear or Eustachian 
tube, I have frequently noticed that the 
membrane never regained its former posi- 
tion. 

The circumscribed depressions were like- ^^^ -^3 
wise fully discussed in previous sections. We have al- 
ready remarked as worthy of note (see page 107), that 
formations analogous to the attenuated sunken cicatrices 
are also observed in cases of catarrh without perforation 
of the membrane, and that only the development of the 
depression while the case is under observation can de- 
cide whether cicatrix or partial atrophy is present, since 
the appearances are precisely the same. The circum- 
scribed depressions which arise from atrophy are found 
at one or more points on the membrane. In one case, in 
consequence of many sharply defined depressions, it pre- 
sented the appearance of a surface with shining facets. 
Since experience shows that several perforations can sel- 
dom occur in the membrane, we may therefore infer, 
where there are several limited depressions, even if there 
has previously been perforation, that the thinned spots 



152 Membrana Tympani, 

may still be the result of atrophy, caused by inflamma- 
tion of the membrana tympani attending purulent catarrh 
of the middle ear. 



Appearances produced hy Movements of the Memhrana 

Tympani, 

The variations in the pressure of air in the cavity of 
the tympanum, when not too inconsiderable, always pro- 
duce a recognizable movement in the elastic membrane. 
There is a difference, however, in the mobility of the 
various portions of the membrane, — the peripheral parts 
and those next to the manubrium are moved only to a 
slight extent, while there is considerable motion in those 
lying midway between the periphery and manubrium. 

These rapidly occurring changes in the position of the 
membrane in the normal condition are, in the majority 
of cases, recognized either by a perceptible alteration in 
the form of the cone of light, or by a visible movement 
of that portion of the membrane lying behind the ma- 
nubrium. We have, however, observed cases where no 
change in the membrane could be perceived on forcing 
air into the middle ear (see page 28). 

If we examine a normal membrana tympani while 
air is being forced into the middle ear by the Valsalvian 
experiment, by the new method or by the catheter, we 
see no change in the position of the manubrium, al- 
though it moves from a quarter to haK a line. The 
posterior portion sometimes moves very noticeably, and 
a fainter reflection of light appears upon it. The cone 



Abnormal Movements, 153 

of light pushes outward, often becomes indistinct and 
faint, and alters its shape and size, but in very different 
degrees in different individuals. When the pressure of 
the air ceases the membrane at once regains its former 
aspect. 

The case is different in diseases of the middle ear^ and 
in morbid clianges of the membrane itself. When the 
Eustachian tube is impervious, and the pressure of air 
employed cannot overcome the obstruction, and when 
there are extensive adhesions of the membrane to the 
inner wall of the tympanum, or when there is considera- 
ble thickening of the membrane, no movement will be 
perceived. An irregular movement of certain points 
occurs in limited adhesions, in irregular thickening, in 
cicatricial formations, and in partial atrophy of the mem- 
brane. 

In other cases, on the contrary, we observe very free 
movements of the membrane if the Eustachian tube is 
abnormally wide (Yon Troltsch, Autopsies in cases of 
Deafness), and the stream of air presses with full force 
into the cavity of the tympanum. 

The movements will be so much the greater if the 
membrane, from atrophy of its substantia propria or of 
all its tissues, has lost a part of its elasticity. Not un- 
frequently I have seen, in case of persons who had suf- 
fered from chronic catarrh, and had frequently employed 
the Yalsalvian experiment for the improvement of their 
hearing power, a great change in the position of the 
usually dull and lustreless membrane, and a perceptible 
protrusion of the malleus handle. I have observed 



154 Membrana Tyrrvpani. 

still greater movement in membranes wliicli, in the 
course of chronic catarrh of the middle ear and 
Eustachian tube, have been reduced by atrophy to a 
transparent pellicle, not unlike a thin layer of collodion. 
The membrane in these cases appears relaxed when in 
a state of repose, and lies in numerous folds, on the 
summits of which striated reflections are seen running 
out like radii. In the Yalsalvian experiment the lateral 
portions of the membrane, especially, swell out very 
strongly, the folds disappear, and the reflections become 
more faint. When the pressure ceases, the membrane 
sinks back and becomes folded again. For this condi- 
tion of the membrane the term " CoUapsus Membranae 
Tympani," which Wilde employed for inward curvatures, 
would be more suitable, — by no means, however, in the 
sense of a primary affection. 

Perceptible movements of the membrane, furthermore, 
occur on rarefying the air in the tympanum. Thus, in 
the act of swallowing with the mouth and nostrils 
closed, we likewise see the light spot change its form, 
but in a diferent manner in different individuals. Some- 
times it seems as if the cone of light made a move- 
ment outward, by which the erroneous impression 
might be given, that the air was forced into the tympa- 
num by the act of swallowing with closed nostrils. 
A rarefaction of the air can, however, be easily proved 
by the movement of a drop of colored fluid in a manom- 
eter fixed air-tight in the meatus. 

We must further add on this point, however, that 
at the first instant of the act of swallowing, a slight 



MoveTnents in Swallowing. 155 

condensation of the air in the cavity of the tympanum 
really does occur, but afterwards a considerable de- 
gree of rarefaction. This can be most clearly seen in 
membranes having thin, depressed cicatrices, or circum- 
scribed atrophied spots. At the first instant of the 
act of swallowing with the nostrils closed, the de- 
pression swells out quickly, but immediately sinks 
back again toward the promontory still deeper than 
before. 

If the nostrils are not closed during the act, we ob- 
serve, as a rule, no movement in the normal membrane. 
On the contrary, in membranes with thin, depressed cica- 
trices, or atrophied, I have seen marked movements, and 
changes in the form of the light spot. The fact that, in 
these cases, movements of the membrane result from the 
simple act of swallowing, while they do not occur in the 
normal condition, is explained as follows : When we swal- 
low without closing the nostrils, a slight momentary 
rarefaction of the air in the throat occurs, which, since the 
Eustachian tube is simultaneously opened, also affects 
the air in the tympanic cavity. The pressure of the 
external air would now force the membrane inward, but 
that it offers resistance in consequence of its elastic 
elements ; and, since this power of resistance is greater 
than the force which is exerted by the slight difference 
between the pressure of the air within and that mthout 
the tympanum, no movement ensues. On the contrary, 
where there are circumscribed thin sjDaces, or atrophy of 
the entire membrane, its elastic resistance is so considera- 
bly diminished that, even in slight variations inthe pres- 



156 Membrana Tympani. 

sure of tlie air in the cavity of tlie tympanum, move- 
ments of certain portions must result. 

As a rule, no changes are perceptible on the normal 
membrane during the movements of respiration / only 
in rare cases have I seen, in tranquil respiration, a syn- 
chronous to and fro movement of the membrane, from 
which it was inferred that the Eustachian tube was wide 
open. If, however, by quickly repeated respirations we 
make the air pass rapidly through the nasal cavity, the 
Eustachian tube will frequently, but not always, become 
pervious, from the increased pressure in the pharynx, and 
a movement of the membrane result fi'om the trans- 
mitted fluctuation of the pressure of air. We maintain 
this opinion (see Report of the Session of the Academy 
of Sciences in Vienna, March, 1861), and must call it an 
error when it is affirmed that the tube is opened with 
every respiratory movement. 

Pulsations are to be classed among the frequent phe- 
nomena on the membrane. Wilde was the first to call 
attention to their presence in perforation, and they have 
hitherto been regarded as pathognomonic. I have al- 
ready, in a former work (Zeitschrift fiir pract. Heil- 
kunde, 1862), spoken of the perception of pulsating 
movements upon imperforate membranae tympani, and 
these observations have been very recently confirmed by 
private communications f romVon Troltsch and Schwartze. 
The normal membrane, on account of the slight capacity 
of its blood-vessels, shows no pulsation. We can, how- 
ever, produce it, if we irritate the membrane by fre- 
quently touching it, inducing a greater fulness of its 



Pulsations, 157 

v^essels. We may perhaps even then perceive no pul- 
sation on inspection, but it becomes very apparent if, as 
I liave seen in some cases, a thin bit of straw, extending 
out of the meatus as an indicator, be carefully attached 
to the membrane by a little drop of gum, the external 
end of the indicator moving synchronously mth the 
pulse. 

I first noticed pulsations of the imperforate membrane 
in some cases of acute catarrh of the middle ear. Below 
and behind the manubrium, on the intensely injected and 
serum-soaked membrane, I saw one or more punctiform 
reflections, which moved to and fro with the movements 
of the pulse, or disappeared during the diastole and 
came to view with the systole. 

On the perforated membrane we find one or more 
reflections with pulsatory movement. The pulsation is 
seen in the perforation on a reflection either from an air- 
bubble, or frequently from a drop of pus. It sometimes 
ceases, but usually becomes very active when we irritate 
the meatus by touching or syringing it. Now and then 
we notice numerous striated reflections from the secretion 
lying on the membrana tympani, which in the move- 
ments of pulsation cross each other in various directions, 
and present an appearance very similar to the motions of 
a fluid in which a number of maggots are stirring. Pul- 
sation on perforate membranes is caused by expansion 
of the vessels of the swollen and softened mucous lining 
of the middle ear, and of the membrana tympani itself. 
Since the advancing blood-wave expands the vessels, the 
area of the tympanic cavity is diminished, the accumu- 



158 Membrana Tym])am, 

lated secretion and tlie air compressed and pushed toward 
tlie opening. 

In certain cases I have seen a reflection, formed upon 
the secretion in the perforation, move to and fro very 
perceptibly in the act of swallowing without closure of 
the nostrils. Inasmuch as I convinced myself in these 
cases that no air could enter the cavity of the tympa- 
num through the Eustachian tube, I was forced to the 
conclusion that the secretion accumulated in the tube 
and middle ear was set in motion by the movements of 
the tube itself. 

We herewith conclude our observations upon changes 
of the membrana tympani occurring in diseases of the 
ear. After having, as we think, sufficiently proved the 
importance of a knowledge of them in the diagnosis of 
aural disease, we must still make especially prominent 
the value of inspection of the membrane in judicial and 
military affairs. How often ^re persons who are not 
subject to military duty sent from the rendezvous for 
a longer time to the inspection-room, under suspicion of 
simulating deafness, when subsequent examination 
showed clearly perceptible changes in the membrane, 
such as perforations, depressions, or calcareous deposits. 

The proof of demonstrable changes in the membrane 
is still more important in medical jurisprudence. 
Lesions from blows upon the head will be easily recog- 
nized when recent. If the medical juiist rests his de- 
cision on a later examination, and the lesion has, in the 
mean time, completely healed, though a certain degree of 



Medical Jurisprudence. 159 

dea;fness still remains in consequence of deeper-seated 
changes, then that decision will not be so favorable for 
the injured party as it would have been had the exam- 
ination been made directly after the injury. 

Still another case : — A person hard of hearing gets into 
a scuffle, and then prosecutes his antagonist for injuring 
his ear. If, now, the medical jurist discovers soon after 
the occurrence a calcareous deposit, or a depression in 
the membrane, — changes which occur only in affections of 
longer duration, — his decision will be essentially different 
from what it would have been had the examination been 
deferred to a later period, in order to first obtain the 
opinion of an expert. 

Besides the previously mentioned works on aural surgery, the fol- 
lowing papers are worthy of notice : 

Moos : Ueber plotzlich entstandene Taubheit. Wiener med. Woch- 
enschrift. 1863. 

Lucae : Anatomiscb-pliysiologisclie Beitrage. Yirchow's Archiv. 
B. xxix. 

Pagenstecher : Deutsche Klinik. 1863. Nos. 41-43. 

Yoltolini : Yirchow's Archiv. 

At the beginning of this work we remarked that in a 
considerable number of cases of deafness no abnormal 
changes are perceptible upon the membrana tympani. 
If, now, we find the Eustachian tube quite pervious, and 
little or no improvement in the hearing after the employ- 
ment of the air -douche, it is difficult, often impossible, to 
determine whether the affection is of the tympanic cav- 
ity or of the labyrinth. , 

These cases have hitherto all been classed together as 
nervous deafness (Kramer) ; but since pathological anat- 



160 Membrana Tympani, 

omy has been recognized and cultivated as tlie ground- 
work of all accurate knowledge in otology as well as in 
other branches of medicine, we have been led to the con- 
clusion that, in a great number of these cases, the seat of 
the trouble is in the cavity of the tympanum. The dis- 
sections of Toynbee and Von Tro tsch sufficiently prove 
this ; and I am of the opinion, from my own dissections, 
that circumscribed affections quite certainly do occur in 
the middle ear which lead at one time to adhesion be- 
tween the malleus, incus, and upper wall of the tym- 
panum, at another, to union of the stapes with the edge 
of the fenestra ovalis, without the membrana tympani or 
the Eustachian tube being in any way sympathetically 
affected. 

We must frankly confess that the diagnosis in these 
cases still rests on uncertain grounds ; and it will be 
the task of physiological and pathological investigation 
to establish a method of discriminating the cases of im- 
pairment of function which are caused by obstacles to 
the transmission of sound in the cavity of the tympanum, 
from those caused by primary affections of the terminal 
branches of the auditory nerve in the labyrinth. 



SUPPLEMENT 



A. 

Accumulation of Serum in the Tympanic Cavity — 
Diagnosis and Treatment. 

The mucous layer of tlie membrana tympani is usually 
afectecl in those diseases of the lining membrane of 
the middle ear which are accompanied by mucous 
secretion. 

The changes in the membrana tympani occurring in 
consequence — namely, softening of the vascular and 
epithelial layers of the mucous coat, simultaneous soften- 
ing of the substantia propria, and frequently, also, con- 
gestion of the dermoid layer — cause such opacities that, 
as a rule, we can no longer see the structures or the 
morbid products lying behind the membrane. 

But occasionally cases present themselves in which 

the membrana tympani is not involved in the diseases 

affecting the lining of the cavity. The membrane then 

possesses such a degree of transparency that it admits 

light enough into the cavity to enable us to discover, 

without much difficulty, changes behind the membrane, 

such as congestion of the mucous membrane of the prom- 

11 



162 Supplement 

ontory and the accumulation of secretion, provided 
these lie within the field of vision. 

The literature of aural surgery has hitherto furnished 
only a few observations upon this point. Von Troltsch, 
by whose meritorious labors the method of examining 
the membrane was so essentially improved, first recog- 
nized by ins23ection the presence of mucus-bubbles in 
the tympanic cavity (Krankheit des Ohrs, 2 Auflag. 
1862). Another observation was made by Lucae, who, 
after injecting the middle ear through the Eustachian 
tube, could see the injected fluid through the membrane. 
But in that case the membrane was abnormally thin at 
one point, and consequently very transparent. 

After numerous personal observations, I can testify to 
the presence of visible mucus-bubbles, such as Troltsch 
describes, in the tympanic cavity. Very frequently I 
have seen them in large children who, in consequence of 
tonsillitis, or of a severe cold in the head, suffered from 
catarrh of the middle ear by transplantation. Within 
the field of vision were, generally, a number of sharply 
defined circles, of varying size, which, upon continued 
observation, sometimes changed their place. The open- 
ing of the Eustachian tubes by my method caused an 
entire or jDartial disappearance of the accumulated bub- 
bles, or a brisk movement and change of place. 

Of not less interest are the accumulations of serum in 
the cavity, which have not hitherto been described, but 
which can be diagnosticated by inspection. 

I have thought the following observations worthy of 
commimication, inasmuch as the appearances in several 



Supplemoit 163 

of the cases observed by me were so distinctly marked, 
and tlie patients also presented another set of symptoms 
of diagnostic interest. 

Upon the 24th of May, 1866, Franciska L., a washer- 
woman, presented herself at our clinic for aural disease, 
in the Genei-al Hospital, with the statement that four 
weeks previously, while washing at the well, she had 
suddenly experienced a ringing in both ears, which was 
soon followed by considerable deafness. She ascribed 
this to the sudden change of temperature to which she 
was exposed in transferring her washing from the warm 
to the cold water. From that time the ringing con- 
tinued uninterruptedly in both ears. The deafness occa- 
sionally varied, the patient hearing better upon some 
days, though the improvement was of very short dui'a- 
tion. At the same time she felt a great pressure and 
heaviness throughout the whole head. Sounds and 
voices appeared deadened and as if they came from a 
distance, and her own voice had an increased resonance. 
The deafness was so marked, that she could understand 
speech only at the distance of one foot from the right 
ear, and two or three inches from the left. 

The objective examination gave the following result : 
The rnembrana tympani, at first sight, seemed very much 
sunken ; the manubrium somewhat foreshortened by too 
great projection of its lower end into the tympanic 
cavity, and the short process was very prominent, as 
well as the folds running forward and backward from 
it. The whole manubrium is sharply defined, and be- 
hind it, in the posterior upper quadrant, the long shank 




164 Supplement 

of the incus can be seen sliinino; throno;li tlie mem- 
brane. The membrane is not opaque, but rather is very 
transparent, and of a yellowish color mingled with a 
light tint of ^dolet. Upon closer examination, however, 
about one-half of the membrane, in its ujDper portion, 
appears of a lighter shade than the lower 
part, which is dark gray. The boundary be- 
tween the two diferently colored ]3ortions is 
very distinct, and is marked by a fine black 
line, which, beginning at the anterior periphery of the 
annulus tympanicus, at about the height of the middle 
of the manubrium, extends to the posterior perijDhery, 
being concave above. This line has the appearance of a 
black hair lying u]3on the membrane. 

From these different shades of color in the mem- 
brana tympani, so sharjDly defined, we inferred the ac- 
cumulation of a fiuid in the sloping portions of the 
tympanic cavity ; and, therefore, causing the patient to 
lie down, ^ve examined the membrane while she was 
in the horizontal position. After a few minutes we 
could see that the black line had changed its place, 
still Jiaving a horizontal position ^^dth a concavity 
above, and situated j)arallel to and just behind the 
manubrium. Accordingly, the difference in 
color mentioned was not j)resented now, as 
before, by the up2:)er and lower, but by the 
anterior and posterior portions of the mem- 
brane. When the patient stood upright the original 
appearance returned (Fig. 1), so that the left mem- 
brana tympani showed no essential changes besides a 




Siqyj^lemenf. 165 

distinct concavity, a dark-gray color, and marked liyper- 
semia of tlie vessels of tlie maniibrinm. 

As there could be no doubt now tliat in tlie case 
before us ^ve liad an accumulation of fluid in tlie 
tympanic cavity, air was forced througli tlie Eustacliian 
tube by my method, and tlie membrana tymj)ani in- 
spected at tlie same time. At the moment the air 
entered the cavity the following changes occurred. The 
lateral portions of the membrane bulged out, and in- 
stead of the distinct limitation in the colors of the 
membrane before described, we saw almost the whole 
field covered with rings of various sizes, having dark 
contours. The explanation of this was not difficult. 
The air streaming into the cavity caused 
the formation of bubbles in the serous 
fluid, visible through the membrane as 
sharply outlined rings (Fig. 3). 

This change in the appearance of the membrana 
tympani was also accompanied by a striking improve- 
ment in the hearing distance, which upon the right side 
increased fi'om one foot to more than forty ; upon the 
left, however, the increase was not more than six feet. 
"With this sudden improvement in hearing thei'e was, 
according to the statement of the patient, a marked 
relief in the head symptoms, for the heaviness and 
pressure ceased, and the loud ringing immediately dis- 
appeared. A great crackling ^vhich she perceived soon 
after air was forced into the cavity proceeded from 
the movement of the air-bubbles. (Schwartze.) 

Upon inspection the following day a distinct chano-e 




166 Supplement. 

in the serous fluid could be proved; for we saw the 
dark line which formed the boundary between the air 
and serum much lower, so that the latter occupied 
scarcely a fourth j)art of the visible field. The hear- 
ing distance was indeed less by several feet than upon 
the previous day, but increased again to six or eight 
feet ujDon the employment of my method. After the 
air-douche, bubbles could be seen, though in much 
smaller number than on the previous day. 

The f mother treatment of the case consisted in the 
employment of the air-douche every second day. The 
mucous membrane of the nares and pharynx being at 
the same time softened, and secreting abundantly, a 
little pulverized alum was blo^^m in through a rubber 
tube, of the size of a large catheter, which was intro- 
duced into the pharyngeal space, in the neighborhood 
of the Eustachian tube, through the lower nasal pas- 
sage. 

The result was so favorable that in the coui'se of 
three weeks the hearing distance could be considered 
normal, and nothing of an abnormal character could 
be discovered in the membranes. 

If we seek the cause of serous accumulation in this 
case, two facts must be considered, namely: The im- 
perviousness of the Eustachian tubes and the hyper- 
semic condition of the tympanic cavities. In the 
normal state, the lining membrane secretes a small 
quantity of serous fluid, which is carried by the ciliary 
movement in the cavity toward the tube, and flows 
through it into the pharynx. An obstruction of the 



Sniyplement 167 

tube preventing tlie escape of tlie serum may cause an 
accumulation. Clinical experience, however, teaclies 
that the tube may be impervious for a long time with- 
out any such accumulation resulting. Especially can 
this be demonstrated in those patients whose mem- 
branse tymj^ani do not lose their transparency even 
when greatly sunken. In addition, then, to the swel- 
ling and accompanying closure of the tube, there must 
also be in these cases a more than ordinary degree of 
congestion of the mucous membrane of the cavity, 
causing the secretion of a greater quantity of serum. 

In certain cases we can scarcely doubt the serous 
character of the secretion. The fluid would not have 
changed its place so rapidly and readily if the secretion 
were tenacious mucus, such as occurs in catarrhal auc- 
tions of the mucous membrane of the tympanic cavity. 
That viscid masses in the ca\dty cannot be easily moved 
I could plainly see in several autopsies which I made 
upon persons who died of puerperal fever, and during 
the disease had been attacked by catarrh of the middle 
ear. The muco-23urulent secretion, mingled ^vith streaks 
of blood, was here so tenacious that it could only be 
removed in coherent masses. 

The recovery of hearing in the case related was 
effected by rendering the Eustachian tube pervious. 

The pressure of air employed, in accordance with my 
method, not only completely accomplished this, but 
removed the accumulated fluid from the cavity. Cathe- 
terization of the tube was therefore entirely unneces- 
sary. Indeed, according to my experience, it is proba- 



168 Supplement. 

ble that recovery would not have been brought about 
by its employment in so short a time. This opinion is 
substantiated by similar therapeutic trials, which were 
made in a large number of cases of acute catarrh of the 
tube and cavity. 

In the great majority, the cure or improvement of the 
affection in the middle ear was quicker and more perma- 
nent when my method was employed than when it was 
effected by catheterization. This was most striking in 
those cases in which the catheter had already been used 
for some time mth little and temporary improvement, 
my method, in the same cases, working quicker and more 
permanent results. The reason of this appears to be 
found not only in the difference in the amount of pres- 
sure exercised in the two methods, but in the fact that the 
catheter comes into immediate contact with the mucous 
membrane of the tube and thus causes a new irritation and 
swelling, whilst with my method no irritation of the 
tube by the instrument can take place. In certain cases 
of chronic catarrh of the middle ear w^e are able to prove 
clearly that the swelling of the lining of the tube is 
increased by the use of the catheter. For if before its 
employment we have recognized the entrance of air into 
the tympanic cavity, either by hearing through the 
otoscope the sound of its impulse upon the membrana 
tympani, or by perceiving upon inspection the bulging 
out of the membrane, then, indeed not unfrequently, 
after the use of the catheter we may convince ourselves 
that it is either more difficult or utterly impossible to force 
air into the cavity by the Valsalvian experiment — a fact 



Su])]^lement. 109 

whicli can only be accounted for by increased swelling 
of the lining of tlie tube, consequent upon tlie mechani- 
cal ii'ritation of the catheter. 

Note. — To the cabove we would add the following observations, as the result 
of later experience in the treatment of serous accumulation in the tympanic 
cavity : — 

In the majority of Dr. Politzer's cases the treatment has consisted in the 
employment of his method for inflating the middle ear, with the following 
modification. After the patient has taken a little water into his mouth, his 
head is bent over to the opposite side and somewhat forward, and in this 
position the air-douche is employed. 

With the head thus inclined, the Eustachian tube takes such a direction 
that its pharyngeal end is turned downward, while the tympanic end is 
directly upward, and, therefore, when the air enters the cavity the serous fluid 
will be driven downward into the pharynx. That the fluid in the cavity was 
really diminished was proved by inspection, for its level was much lower 
than before the experiment. In several othet cases the fluid accumulation 
was lessened when Dr. Politzer's method was employed, the patient lying 
upon a sofa with the head bent backward. In this position the fluid is driven 
through the openings in the posterior wall of the tympanum into the mastoid 
cells, where it is absorbed. 

The secretion is not always so fluid, however, that it can be thus easily 
removed from the tympanic cavity, for when it has been retained for a long 
time a gelatinous, viscid matter is formed. This will either be absorbed in 
course of time, or removed by the employment of Politzer's air-douche, or by 
the catheter. 

In such cases, when the membrane was much sunken, and presented a dark, 
greenish-yellow color, Dr. Politzer, after using the air-douche with only tem- 
porary success, performed paracentesis, and immediately afterward forced air 
through the ear by his method, thus driving the mucous matter out into the 
external meatus. The opening in the membrane usually closed by the fol- 
lowii'g day, and the hearing power was restored to its normal standard, or 
returned after several applications of the air-douche. (A. M.) 



170 Supplement 

B. 

A Method for l^reventing the Closure of Artificial Per 
f orations of the Meinbrana TympanL 

The excision of a piece of the membrana tympani 
in aural patients, in order to imj^rove the diminislied 
hearing power, was, as you know, recommended by Rio- 
Ian, even in the middle of the l7th century. It was 
scarcely noticed by the distinguished surgeons of the 
17th and 18th centuries, probably because the results 
were so uncertain. The first communications of scien- 
tific value date from the commencement of the present 
century. For Astley Cooper and Himly simultaneously 
and inde23endently of each other had performed the 
operation, and, encouraged by the immediate favorable 
results, had urgently recommended it. But, although the 
immediate results were so favorable. Cooper and Himly 
soon became convinced that the wondei-ful success was 
only transient, for the artificial opening was almost 
always closed again by neoplastic cicatricial tissue, and 
the former degree of deafness returned. 

In the mean time accounts of Cooper's brilliant success 
were published upon the continent ; and while Cooper 
himself, convinced of the inutility of the operation, had 
entirely abandoned it, still for a long time it was per- 
formed in France and Germany with unparalleled zeal, 
upon many hundred patients. To Himly belongs the 
credit of setting a limit to the pernicious employment of 
an operation, practised with damage to so many aural 



Siipplennent Ivl 

patients. By bringing together tlie results obtained by 
tlie reliable surgeons of tliat day, lie has furnished proof 
that in very few cases did even a slight benefit result 
from the ojDeration, whilst no improvement was obtained 
in the majority of patients upon whom it was performed 
without regard to pathologico-anatomical changes, pre- 
sent in the middle ear and up to that time little known. 

Attempts, indeed, to keep the perforation open were 
not wanting. Bits of catgut, little rods of fish-bone, and 
lead wires were introduced, in the anticipation that after 
long continuance in the opening the edges of the wound 
would heal over. But a closure of the perforation al- 
ways followed their removal. 

There is an interesting report by Bonnafont^ of a 
case upon which he operated. Excision of a piece of 
the membrane was practised in case of a very deaf per- 
son, and it was followed by considerable improvement 
in hearing. In spite of- frequent cauterization of the 
edges of the wound with a pencil of lunar caustic, and 
the introduction of catgut into the artificial opening, 
it was closed after six months by cicatricial tissue, 
with loss of the improvement in hearing which had been 
obtained. In the course of the next two years the opera- 
tion was repeated upon the same person nine or ten times, 
always followed, however, by closure of the perforation. 
After performing the operation once more upon this pa- 
tient, Bonnafont, in order to prevent cicatrization, intro- 
duced into the opening a silver canula, whose length was 
equal to that of the whole external meatus, and permitted 

* Traite theorique et pratique des maladies de I'oreille. Paris, 1860. 



172 S'ujpplement, 

it to remain tliere forty-five days. Six clays after its 
removal, however, the perforation had considerably dimin- 
ished in size and it vras necessary to remove a smaller 
metal canula which had been introduced, irasmuch as 
it became troublesome to the patient, and thus again 
the closure occurred as before. 

The disagreeable results of the operation, and the impos- 
sibility of keeping the artificial perforation open, have 
led to the almost entire abandonment of the procedure, 
especially during the last tw^enty years or more. Only 
very lately was it resumed, and one would think that he 
who should undertake to introduce an operation gene- 
rally declared useless, would present a new method for 
keeping the perforation open. This was not the case, 
however, for it was rather by means of a useless compli- 
cated apparatus that excision was performed in case of 
an old man, and a portion of the membrane torn away. 
I had an opportunity to convince myself that the hear- 
ing distance was essentially increased, and the subjective 
sounds, as the patient stated, had diminished. Although 
the frequent employment of the Valsalvian experiment 
was enjoined upon the patient by the operating surgeon, 
the perforation, nevertheless, closed. When he presented 
himself during my course, at the general hospital, I could 
demonstrate to the students the cicatrix occupying the 
site of the artificial opening. Not only had the improve- 
ment which followed the operation disappeared, but the 
deafness was even more marked, and the subjective 
sounds were intolerable, as before. Another operation, 
performed by the same surgeon, had no better result 



8'U])][)lement. 173 

suppuration and a renewed closure of tlie perforation 
following. Several years have j)assed since tliat time, 
and how honestly one means to deal with science is seen, 
when, shortly after an operation, with great pomp he 
carelessly j)roclaims to the world a favorable result, 
but at a later period neglects to confess the failure. 

We must therefore agree with Schw^artze, who from 
his own experience declares that artificial perforations 
of the membrana tympani are, almost without excep- 
tion, closed by cicatricial tissue, and the operation is 
therefore entirely useless, so long as no means are found 
for keeping them open. 

Very recently the opinion was expressed by Wreden, 
that a permanent opening could be established by cut 
ting out a piece of the handle of the malleus (sphiro- 
tomie). He thought that, as a portion of the blood- 
conveying vessels w^ould be removed with the handle, re 
generation of the membrane at the gap w^ould thereby 
be prevented. Apart from the fact that clinical experi- 
ence is wanting concerning the result of the operation, 
some objections arise even to the theory. For the vessels 
which proceed fi'om the external meatus to the mem- 
brana tympani anastomose abundantly, by means of radi- 
ating twigs, wdth a vascular wreath upon the periphery 
of the membrane and with the arteries in the cavity of 
the tympanum. This can be seen in a successful injec- 
tion of the human membrana tympani."^ Hence, if a 
piece of the malleus ^th the blood-vessels be excised, 

* Compare Prussak : Zur Physiologie und Anatomie des Blutstromes in der 
Trommelhohle. Yerhandlungen des kgl. sachsisch. Academie. 



1 74 Supplement 

a collateral circulation is necessarily established, by which 
regeneration of the membrane will be effected. 

Whether or not a permanent opening in the membrane 
can be obtained by means of the galvano-caustic, as late- 
ly proposed by Voltolini, is yet undetermined, for both 
the data of Voltolini and reports adverse to the practice 
are wanting. 

The means which I have employed for keeping the ar- 
tificial perforation open consist in the introduction of a 
liarcUmhher eyelet, having a groove upon its peripliery^ in 
tvliicJi the edges of the perforation lie^ thiis holding the 
eyelet fast. Its permanent connection with the membrane 
is secured by the growth of the edges into the groove. 

The method of procedure is as follows : The mem- 
brana tympani being well illuminated, a linear incision 
is made in the posterior lower quadrant of the mem- 
brane, through a hard-rubber speculum, by means of a 
double-edged cataract-needle, which is bent at an angle, 
and is about five and a haK centimetres in length. Then 
we introduce into the slit a bit of moistened laminaria, 
two inches long and one-quarter of a line in thickness, 
allowing it to remain in the ear several hours. The lam- 
inaria gradually swells, causing more or less pain. After 
its removal a roundish opening appears in the membrane, 
into which the eyelet is introduced by means of a forceps. 

The eyelets which I use (manufactured by Joseph 
Leiter of Vienna) are from a line to a line and a haK in 
length, and the longest diameter of their oval aperture 
is half a line. Upon the outer end of each eyelet there 
is also a little aperture at the side, for the introduction 



Supplement. 175 

of a silk tliread, by Avliicli the eyelet can be witliclrawn 
if it accidentally slips from the forceps. The thread, 
however, is carefully removed when the instrument is in 
its proper position. 

We are also influenced, as will be seen hereafter, in the 
choice of a place for the establishment of a perforation 
by the presence of a cicatrix in the membrane. If a 
cicatrix be perforated it will be unnecessary to accom- 
plish dilatation by means of the laminaria, for, elastic ele- 
ments beino: absent, there will be no resistance to the in- 
troduction of the eyelet into the aperture. The hard- 
rubber eyelets are light, are bad conductors of heat, and 
cause no inflammatory irritation in the membrane, the 
patient being scarcely aware of the presence of a foreign 
body in the ear. We now proceed to a description of 
the first case operated on by us. 

Upon the 2-2d of October, 1868, Anna P., set. 48, 
wife of a joiner at Vienna, presented herself at our clin- 
ic for aural patients in the General Hospital. According 
to her statement, she had two years before suddenly ex- 
perienced a severe pain in her left ear, which ceased af- 
ter eight days upon the appearance of a cojdIous otorrhoea. 
She said that the discharge from the ear continued for 
some days, but deafness and whistling of air through the 
meatus were of several weeks' longer duration. The se- 
cretion was entirely stopped by an ear- wash which a sur- 
geon had ordered, and the hearing was considerably im- 
proved, and continued so for two months. After this time, 
however, deafness rapidly came on in this ear, and Avas 
accompanied by very severe and troublesome subjective 



1 ? 6 Supplement 

symptoms, a ringing and roaring wliicli continued unin- 
teiTuj)tedly. The deafness lias been as great for a year 
past as it is at tlie present time. 

The disease in the right ear is of three months' dura- 
tion. Here also the affection began Avith severe pain, 
which continued for three weeks, although a purulent dis- 
charge occurred very early in the disease. The discharge, 
as well as a constant hissing in the ear, has lasted up to 
the present time. 

Upon examination, the left membrana tympani was 
found to have a tendinous gray opacity, the short process 
of the malleus was very prominent, the anterior and pos- 
terior folds were sharply defined, and the less clearly 
marked manubrium was strongly drawn 
inward. Beneath the manubrium was 
a dark, oval, depressed spot, obliquely 
situated, and about a line in transverse 
and half a line in vertical diameter. 
iig:i: Xhis was the cicatrix of the previous 

Left membrana tympani, 
with cicatrix beneath the -r-vcn^-P/^vQ f i rkn 
luanubrium. P^l ^^^ ailOU. 

In testing the hearing power, a cylinder watch could 
be heard only when laid upon the auricle, or when 
pressed upon the temple. Speech could be understood 
only at a distance of three feet. Upon opening the 
Eustachian tubes by my method, the thin depressed cica- 
trix bulged out ; the hearing distance for the watch, 
however, had not increased, whilst for speech the im- 
provement amounted to one foot. 

In the right membrana tympani, in front of, and below, 
the manubrium, we found a perforation as large as a pin- 




Sujpjplement. 177 

head, out of wliicli, upon tlie Yalsalvian experiment, 
came a drop of thick pus, soon followed by several air- 
bubbles. When the pus had been removed from the 
meatus, the watch w^as heard at a distance of two inches, 
speech at five feet, and the ticking of the watch could be 
perceived when laid upon the temple. The tuning-fork 
placed upon the vertex was more distinctly heard in the 
left ear, because, the impediment to the conduction of 
sound out of this ear being greater, the vibrations trans- 
mitted through the cranial bones were retained and more 
clearly perceived. We had, therefore, in this case to deal 
with a purulent catarrh of the middle ear, upon the right 
side, associated with perforation of the membrana 
tym]3ani. 

The same process was also present, at an earlier period, 
in the left ear, though there had been no su]3puration 
from the mucous membrane of the cavity for more than 
a year, and the perforation had been closed by cicatricial 
tissue. The fact that a perceptible improvement in hear- 
ing did not follow upon forcing air into the middle ear, 
led to the conclusion that the deafness was neither the 
result of closure of the Eustachian tube, nor of the accu- 
mulation of mucus in the cavity of the tympanum, but 
was caused by adhesions between the ossicles and the 
walls of the cavity. Since, according to the history of 
the case, the deafness on the left side was inconsiderable 
during the time when the patient could force air through 
the ear, that is, during the existence of the perforation, 
but, on the contrary, attained a high degree when this 

was no longer possible, the conclusion seemed justifiable 

12 



1 78 Sii/p2^lement. 

that, in this case, dense bands of connective tissue had 
fixed the malleus or incus to the walls of the cavity ; 
that so long as the perforation existed the waves of 
sound could pass through it, and, falling upon the base 
of the stapes, reach the labyrinth ; but after the closure 
of the opening the vibrations could not be transmitted 
from the membrane to the stapes, in consequence of the 
impediments presented by the malleus and incus, and 
hence the great deafness. 

The removal of the thin cicatrix was thus indicated, 
so as to admit again the waves of sound into the cavity 
through the re-established perforation. Therefore I 
undertook the operation, upon the 26th of October. 
Having introduced a large hard-rubber speculum into 
the external meatus, I illuminated the membrane by 
means of a mirror fastened to spectacle-frames, and 
divided the cicatrix in the direction of its longest diame- 
ter, using the double-edged cataract-needle. The pain 
caused by the incision was very little. Then a hard- 
rubber eyelet, having several grooves, was grasped mth 
the forceps, and pushed through the incision into the 
cavity of the tympanum to the depth of half a line 
(Fig. 5). The thin and inelastic cica- 
trix presented very slight resistance, and 
the patient had not the least unpleasant 
sensation in the ear, either during the 
introduction or afterward. Through 
the aperture of the eyelet we could now 
see the pale orange-colored mucous membrane of the 
promontory, and the patient stated, without previous 




Fig. 5. 



Su])])lement. 179 

questioning, that she suddenly heard better, and that the 
subjective sounds had considerably abated. 

After I had convinced myself, by inclining the head 
of the patient to the left, and severely shaking it, that 
the eyelet was firmly held in the perforation, that, con- 
se(xuently, the edges of the opening were lying in the 
grooves, I proceeded to test accurately the hearing dis- 
tance. The watch, which before could only be perceived 
upon contact with the auricle, was now^ heard at the dis- 
tance of nine inches. The hearing distance for speech 
was only three feet before, but now it had risen to more 
than forty (measured at Oppolzer's clinic). I was able, 
repeatedly, to verify this striking improvement during the 
weeks follo\ving, and to-day, thirty-six days later, the 
condition of the membrane is just the same as immedi- 
ately after the operation, the eyelet retaining its original 
position, and not the slightest change affecting the rest 
of the membrane. The improvement in hearing also 
remains the same, and the formerly intense subjective 
sounds have almost entirely disappeared. The patient 
does not notice at all the presence of the eyelet in the 
ear. She remains under observation, and I will not fail 
to report further concerning her, after several months. 

Note. — Since this case was published six months have passed. During 
that time the little eyelet has remained fixed in the membrane without caus- 
ing any inflammation. A change in its position of a line and a half from the 
original has taken place. The hearing power increased from nine inches 
after the operation to twenty-two at the present time, and a whisper is heard 
very distinctly with this ear across a large room. 

[Dr. P. has since that operation performed it on other patients with good 
success. In two cases only he observed irritation and tympanic catarrh, with 
secretion of mucus, so that the eyelet was forced out. (A. M.)] 



180 



8n])])lement, 



C, 



Double Perforation of the Memhrana Tymjmni, 

Ix the foregoing work the author stated that he had 
seen no case in which the membrana tympani was per- 
forated at two points. Since that time, however, he has 
observed several such cases. The diagnosis was in two 
instances coniirmed by post-mortem examination. Of 
foui^ cases observed by Dr. Politzer, the appearance pre- 
sented in three is shown in the accompanying sketch. 
Fig. 6 ; namely, two large oval perfora- 
tions, one before and one behind the 
malleus handle, separated fi^om each 
other by a grayish-yelloXv bridge, formed 
by the handle and a remnant of the 
membrane extending fi-om its end down 
to the inferior periphery. 

In Dr. Politzer' s pathological collection I saw a pre- 
paration of such a membrane taken from a young man 
who had suffered for a long time from 
otorrhoea and died of j)hthisis pulmo- 
nalis. In another |)i'eparation, taken 
from a child who died of pemphigus 
tabescentium, the appearance differs 
from that above described. We find, 
namely, behind the manubrium a perforation two lines 
in diameter, and another as large as a pin-head in the 
lower part of the membrane. Fig. 7. A. M. 





8up2^l€7n€nt, 181 



D. 



Anatomy of the Membrana Tymjpani, 

To tlie anatomical description of tlie membrana tym- 
pani given in tlie foregoing work, we must liere add 
some of tlie results of more recent investigation. 

It is well known tkat tkere is an anterior and a pos- 
terior fold extendino; forward and backward from tlie 
short process of tlie malleus, and tliat tLey are of 
great imj)ortance in diagnosticating anomalies of curva- 
ture, being very prominent in case of abnormal con- 
cavity of tlie membrane. Near tliese folds, at tlie 
anterior upper border of tbe membrane, we find two 
sliort, straight, grayish stripes, which, starting from the 
spinous processes upon the anterior upper portion of the 
tympanic ring, converge toward the short process of the 
malleus. These striae were first described by Prussak. 
In the examination of the living they are very fre- 
quently visible at the place designated, as white lines. 
In the dried preparation they appear somewhat sunken. 
That portion of the membrane which is bounded by 
them, and by the receding ungrooved tympanic edge of 
the temporal bone, is commonly called the membrana 
flaccida sJirapnelli. 

It is much thinner and more relaxed than the other 
portions of the membrane, and usually presents a little 
pitted depression, and forms the external wall of a small 
pocket communicating with the tympanic cavity, which 



182 Su])])lement 

Pnissak lias named " tlie ujDper j^ocket of tlie membrana 
tympani." 

In the dermoid layer of tlie membrane along the mal- 
leus handle, there are, according to Kesel, little glandu- 
lar acini, delicate hairs, and papillae. The vessels along 
the handle form plexuses, which are chiefly venous. The 
arteries pass, in part, directly into the veins, but some 
run in a straight course to the periphery of the mem- 
brane. 

The nerves going from the external meatus to the 
membrana tympani also form plexuses, which accom- 
pany the vessels of the external surface of the membrane. 

The circular fibrous layer is more intimately con- 
nected with the radiating fibres at their peripheral ori- 
gin, but from this point to the malleus handle the two 
layers are easily separable from each other. At the 
handle they become interlaced and are attached to it, 
comj)letely surrounding its lower third. Higher up, the 
circular fibres pass more to the external surface of the 
handle, and thus the latter appears prominent upon the 
inner side of the membrane. At the short process there 
is a layer of true cartilage in considerable amount 
which, according to Griiber, articulates with a corre 
sponding layer of cartilage on the membrana tympani 
Prussak has demonstrated that all of the cartilas^e be 
longs to the malleus, being the residuum of the cartila 
ginous malleus of the foetus, and that no joint-like con 
nection exists between the manubrium and membrane 
This assertion of Prussak was confirmed by Kesel and 
Moos. 



8i(])])lement. 183 

The statement tliat the mucous layer of the mem- 
brana tympani is covered with pavement epithelium 
must be modified, inasmuch as Koppen has in some cases 
found ciliated epithelium upon it. 

Above the short process, according to Bochdolek, is a 
shoi-t canal, the foramen of Eivini, which was formerly 
considered an artificial opening in the membrane. This 
foramen, however, does not appear to be constant. 

Note. — See Prussak, Zur Physiologie und Anatomie des Blutstromes in 
der Trommelhohle. Verhandlungen d. kgl. sachsisch. Academie, 



EEEATA. 



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■' " for " were "' read " was." 

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and '"the conditions, first, of 



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